Application To Establish Delayed Registration Of Foreign Birth {DCH-0855}

APPLICATION TO ESTABLISH DELAYED REGISTRATION OF FOREIGN BIRTH PLEASE READ AND FOLLOW INSTRUCTIONS MAIL APPLICATION AND PROPER FEE TO: For additional information Vital Records Changes Vital Records Changes P.O. Box 30721 (517) 335 - 8660 Mon - Fri 8:0 0 am 5:00 pm ET Lansing MI 48909 PARENT(S) INFORMATION PLEASE PRINT CLEARLY AND LEGIBLY Parent(s) names and complete mailing address are needed to mail the new record. Please provide a phone number to contact you if ther e are questions regarding t his request. Name(s): Mailing Address (Cannot send to General Delivery): City/State/Zip: Daytime phone to contact you: Area Code & Number - - INFORMATION REQUIRED TO PREPARE THE ADOPTIVE BIRTH RECORD First Middle Last Gender Male Female Th is Birth Single, Twin, Triplet, etc. (Specify) If Not Single Born 1 st , 2 nd , 3 rd , etc. (Specify) Date of Birth (Month , Day, Year) Time of Birth Count r y of Birth t ) (or Country, if not U.S.) Mothe (or Count r y, if not U.S.) (Month, Day, Year) American LegalNet, Inc. www.FormsWorkFlow.com Signature(s) This form should be signed by the adoptive parents with their current names. The adoptive parents should verify information listed for the adoptive birth record. Signature of Person Adopting Signature of Husband or Wife (if married) COURT CERTIFICATION The Probate Court of County, Michigan I hereby certify that this court has acknowledged the birth facts of t he foreign born child, and the identified information about the adoptive parents dated . Month Day Year CASE NO. Judge By Probate Register SEAL OFFICE USE ONLY DO NOT WRITE IN THIS AREA Payment The fee for establishing a delayed registration of foreign birth is $ 5 0.00 and includes one copy of the new record. Additional copies of the new record are available for $12.00 each when ordered at the same time. Normal processing time is 5 - 6 weeks. Payment must be made by check or money order p will not be created until the recording fee has been paid. Establish D elayed Registration Of Foreign Birth (Non - Refundable) Fee includes one (1) certified copy of the record. $ 5 0.00 Additional certified Copies $16.00 each $ TOTAL ENCLOSED: $ PENALTIES: Any person who willfully and knowingly makes false application to change a Michigan birth record may be fined and/or imprisoned. MCL 333.2894(1)(b) and (c). DCH - 0855 Rev 10/2013 MCL 333.2830(1) and 333.2 891(5)(b). American LegalNet, Inc. www.FormsWorkFlow.com