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01/2022
Birth Certificate Application
Complete this form to order a certified copy of a Minnesota birth certificate.
The law requires you to provide information to order a birth certificate, Minnesota Statutes, section 144.225, subdivision 7, and Minnesota Rules, part
4601.2600. It is against the law to provide false information to get a birth certificate. You may be subject to fines, jail time or both. Minnesota
Statutes, section 144.227 and section 609.02, subdivisions 3 and 4.
Section A-Information to find the requested birth record
Subject
Subject first name
Subject middle name
Subject last name
Subject’s date of birth (MM/DD/YYYY)
☐
Female
☐
Male
Subject’s city of birth
Subject’s county of birth
Parents
Parent one - first name
Parent one - middle name
Parent one - last name
Last name before 1
st
marriage
Parent two - first name
Parent two-middle name
Parent two-last name
Last name before 1
st
marriage
Section B Requester-Person completing this application
Requester
Requester Full Name
Date of Birth (MM/DD/YYYY)
Requester mailing address – Street
Apt/Unit #
City
State
Requester daytime phone
Requester email
United Parcel Service (UPS) will not deliver to PO boxes or APO addresses.
Marital status is Important.
Records of children born to married parents are “public”. That means that the certificate is available to those listed in items 1-18 below. Records of
children born to single mothers are “confidential” unless the mother chose to make the record public at the time of birth. Only the persons listed below
in items 19-23 may obtain confidential birth certificates.
MANDATORY — Check the boxes below that describe your relationship to the subject of the record:
Birth certificates available to individuals who meet any of the legal requirements in items 1-19 below (Public records)
1. ☐ A parent named on the subject’s record
2. ☐ A grandparent of the subject
3. ☐ A great–grandparent of the subject
4. ☐ A child of the subject
5. ☐ A grandchild of the subject
6. ☐ A great-grandchild of the subject
7. ☐ Spouse of the subject (You must be the current spouse)
8. ☐ I am the subject; I am requesting my own birth record
9. ☐ The legal custodian, guardian, or conservator of the subject (a certified copy of the court order that names you is required)
10. ☐ The health care agent for the subject (A valid health care power of attorney is required)
11. ☐ Subject’s personal representative (we need a notarized statement that says you need a birth certificate to administer the estate)
12. ☐ Successor of the subject (subject is dead; we need a notarized statement that says you need a birth certificate to administer the estate)
13. ☐ Proof that you need a birth certificate for the determination or protection of a personal or property right
14. ☐ Adoption agency — to complete post-adoption search (We need a copy of your Employee ID)
15. ☐ Local/state/tribal or federal governmental agency (We need a copy of your Employee ID) (Best Practice: Wait for family to verify the record)
16. ☐ Attorney- I represent the subject, or a person listed in items 1-14 above
My Minnesota Attorney License Number is:
If you are a NON-Minnesota attorney, attach a
copy of your attorney license.
17. ☐ Pursuant to a valid, certified copy of a U.S. court order (not a subpoena) releasing the certificate
18. ☐ I have a signed and notarized statement from a person above; it specifies the subject’s full name, date of birth, parent’s names, the signer’s
relationship to the subject of the record and it authorizes me to obtain the certificate.
Birth certificates available only under the conditions or to the persons named below (Confidential records)
19. ☐ Parent named on the subject’s record
20. ☐ The legal custodian, guardian or conservator of the subject (a certified copy of a court order naming you is required)
21. ☐ The subject, when 16 years or older
22. ☐ Representatives of Minnesota programs that administer child support, medical assistance, MinnesotaCare, and services under Minnesota
Statutes, sections 124D.23 and 626.556. (Employee ID is required)
23. ☐ Pursuant to a valid, certified copy of a U.S. court order (not a subpoena) releasing the certificate
Signature and Notary (application must be signed in front of a notary if applying by mail or fax)
I certify that the information provided on this application is accurate and complete to the best of my knowledge.
Requester’s signature
Notary Stamp/Seal
Signed or attested before me on: day of , 20_
Notary public signature
My commission expires
Page 2 of 2
01/2022
Birth Certificate Application
Complete this form to order a certified copy of a Minnesota birth certificate.
How many certificates do you want?
Quantity
Fee
Total
One birth certificate sent by First Class Mail®.
1
$26
$26
How many additional certificate(s) do you want to purchase for this birth record now?
$19 each
How many VA birth certificates do you want?
VA birth certificates are available for free- for Veterans Affairs related purposes only
Free
$0
I want rush processing. (Sent by First Class Mail® unless I choose rush delivery below.)
1 Max
Additional
charge of:
$20
I want Express delivery. (Sent USPS Priority Express®. Rush delivery requests are
processed in order receive unless I choose rush processing above.)
☐ Check box if you wish to require a signature for receipt. If you do not check this box, no
signature will be required at the time of delivery.
1 Max
Additional
charge of:
$28.75
For international requests, please go to HTTP://ircal.usps.com to calculate and include
international mailing fees.
There will be a 2.49% convenience fee for credit card transactions.
NOTICE: Fees are payable at the time of application and are non-refundable.
Minnesota Statutes, section 144.226.
Total amount due:
Amount must be at least $26.
If I am not eligible to receive the certificate I requested, Olmsted County Vital Records will contact me. I give Olmsted County
Vital Records & Licensing permission to apply my payment to a follow up application.
How do you want to pay?
☐
Credit card
[Circle One]
MasterCard/VISA/Discover/
American Express
Card holder name (Cardholder must be same as requester)
Expiration date
Card number
3 or 4 digit Security Code
☐
Check
Check #
Make your check or money order payable to Olmsted County.
DO NOT SEND CASH.
Checks returned for non-payment will result in a $30 charge to you. You could
also face civil penalties. Minnesota Statutes, section 604.113, subdivision 2.
☐ Money order
Money order #
Send application and payment to:
Mailing Address
Fax Number
Olmsted County Vital Records Office
151 4
th
Street SE
Rochester, MN 55904-3709
507-328-7965
If you have questions, please contact us at Vitals@olmstedcounty.gov or call (507) 328-7660.