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REQUEST FOR VERIFICATION OF A MICHIGAN AFFIDAVIT OF PARENTAGE RECORD For Additional Information: 517-335-8666 Please type or print clearly and legibly APPLICANT (PERSON REQUESTING VERIFICATION) Agency Name Applicant's Name Mailing Address City/State/Zip DATE: / / Area Code and Phone Number ( ) www.michigan.gov/vitalrecords APPLICANT'S SIGNATURE: (Sign Here) ____________________________________________________ Must be signed in order to process. By signing this application, I understand that I am agreeing to pay for a search of the State of Michigan vital records. This does not guarantee that a record will be found. VERIFICATION INFORMATION - A request for a verification of a Michigan Affidavit of Parentage record (filed in the Central Paternity Registry since June 1, 1997) will be returned to you stamped with an indication that a record was identified which matched the supplied facts, or that no record could be identified which matched the supplied facts. State law (MCL 333.2881(2)) allows for verification of ONLY name of the subject on the Affidavit, date of birth, mother's name and father's name. This information must match exactly what is on the record. No copy of the record or additional information can be verified or supplied by the Vital Records Office. State law requires an $18.00 fee for each search of the facts for verification. FACTS TO BE VERIFIED Names on the Record (Must match exactly what is on record) VERIFICATION STAMP (for Vital Records Official Stamp) _____________________________________________ (Child) First Middle Last _____________________________________________ (Mother) First Middle Last _____________________________________________ (Father) First Middle Last Child's Date of Birth (Must match exact date on record) __________________________________________________ Month Day Year PAYMENT For mail-in requests, payment can be made in U.S. funds by check or money order payable to the "State of Michigan". In addition, cash or a credit card can be used for counter requests. No checks if same-day service is requested. Each Verification Search (Non-Refundable) $ 18.00 $ TOTAL: * EXPEDITED SEARCH Add $12.00 (In addition to the regular search fee) TURN-AROUND TIME REGULAR SEARCH - Processing time for mail-in requests will be approximately 3 weeks, depending on volume of requests received. EXPEDITED SEARCH Processing time for a mail-in request will be approximately 2 weeks, depending on volume of requests received. A counter request will be processed in 1-2 hours. DCH-0569-VERAOP Rev 11-2015 By Authority of MCL 333.2881(2) and 333.2891(4)(f) PAYMENT TO "STATE OF MICHIGAN" $ We cannot process your request without payment. When mailing, please remember to include check or money order. IF REGULAR SEARCH: VITAL RECORDS REQUESTS P.O. Box 30721 Lansing MI 48909 IF EXPEDITED SEARCH: VITAL RECORDS RUSH P.O. Box 30721 Lansing MI 48909 If you wish to have the results of the verification faxed to you, please indicate the fax number here: ( ) ___________________________ American LegalNet, Inc. www.FormsWorkFlow.com
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