APPLICATION FOR FLORIDA BIRTH RECORD
Florida Department of Health - Volusia County
Daytona Beach
New Smyrna Beach
Orange City
8 AM to 4:45 PM 8:30 AM to 4:45 PM 8:30 AM to 4:45 PM
Lunch - open Lunch Noon - 12:30 Lunch Noon - 12:30
(Florida Birth Records are available for 1930 to current year)
Read the FRONT AND BACK of this application: Requirement for ordering: If applicant is self, parent, guardian, or legal
representative, then the applicant must complete this application and provide valid photo identification, if a mail request, a copy of the
valid photo identification must be provided. If applicant is not one of the above, the Affidavit to Release a Birth Certificate must be
completed by an authorized person and submitted in addition to this application form. Acceptable Forms of identification
are the following: Driver’s License, State Identification Card, Passport, and/or Military Identification Card.
SECTION A: REGISTRANT INFORMATION
CHILD’S FULL NAME AS SHOWN ON BIRTH
RECORD
MIDDLE
LAST
SUFFIX
IF NAME WAS CHANGED SINCE BIRTH,
INDICATE NEW NAME
MIDDLE
LAST
SUFFIX
DATE OF BIRTH
MONTH
DAY
YEAR (4 DIGIT)
STATE FILE NUMBER (If known)
SEX
PLACE OF BIRTH
CITY OR TOWN
COUNTY
MOTHER’S / PARENT’S NAME
MIDDLE
LAST NAME PRIOR TO FIRST MARRIAGE
(If applicable)
SUFFIX
FATHER'S / PARENT’S NAME
MIDDLE
LAST NAME PRIOR TO FIRST MARRIAGE
(If applicable)
SUFFIX
IMPORTANT INFORMATION
Any person who willfully and knowingly provides any false information on a certificate, record or report required by Chapter 382, Florida
Statutes, or on any application or affidavit, or who obtains confidential information from any Vital Record under false or fraudulent
purposes, commits a felony of the third degree, punishable as provided in Chapter 775, Florida Statutes.
SECTION B: APPLICANT (adult requesting certificate) INFORMATION
TYPE OR PRINT
Applicant’s Name
FIRST, MIDDLE, LAST (INCLUDING ANY SUFFIX)
SIGNATURE OF APPLICANT
( )
HOME PHONE NUMBER
MAILING ADDRESS (INCLUDE APT. NO., IF APPLICABLE)
RELATIONSHIP TO REGISTRANT
( )
ALTERNATE PHONE NUMBER
CITY
STATE
ZIP CODE
IF ATTORNEY, PROVIDE BAR/PROFESSIONAL LICENSE NO.
CERTIFICATES AND FEES
LICENSE/ BAR NUMBER
NAME OF PERSON REPRESENTED
and THEIR RELATIONSHIP TO
REGISTRANT
Cost
Quanity
Total Cost
Certified Copy:
$15.00
1
=
$15.00
Additional Certified Copy (Optional):
$8.00
x =
(per copy. Must be same registrant)
Expedited Processing (Optional):
$10.00
=
(Only available for applications received by mail. See reverse side of form for instructions.)
Overnight Delivery (Optional):
$10.00
=
(See reverse side of form for instructions.)
Protective Sleeve (Optional):
$3.00
x =
Total Amount Due:
=
FOR USE BY FDOH VITAL STATISTICS OFFICIALS ONLY:
Certificate #:
Application ID #:
Initials:
DH 1960, 4/2016 64V-1.0131, Florida Administrative Code (Obsoletes Previous Editions)
click to sign
signature
click to edit
INFORMATION AND INSTRUCTIONS FOR BIRTH RECORD APPLICATION
COMPUTER CERTIFICATION: computer certifications are accepted by all state and federal agencies and used for any type of
t l
A computer certification has two different formats:
1. A certification of a registered birth (2004 to present), supplies the following facts of birth: Child's Name,
Date of Birth, Sex, Time, Weight, Place of Birth (City, County and Location) and Parents' Information.
2. A certification of a registered birth (1930 to 2003), supplies the following facts of birth: Child's Name, Date
of Birth, Sex, County of Birth and Parents' Name.
AVAILABILITY: Birth registration was not required by state law until 1917, but there are some records on file dating back to 1865.
ELIGIBILITY: Birth certificates can be issued only to:
1. Registrant (the child named on the record) if of legal age (18)
2. Parent(s) listed on the Birth Record
3. Legal guardian (must provide guardianship papers)
4.
Legal representative of one of the above persons
5. Other person(s) by court order (must provide recorded or certified copy of court order)
In the case of a deceased registrant, upon receipt of the death certificate of the decedent, a certification of the birth certificate can be
issued to the spouse, child, grandchild, sibling, if of legal age, or to the legal representative of any of these persons as well as to the
parent.
Any person of legal age may be issued a certified copy of a birth record (except for those birth records under seal) for a birth event
that occurred over 100 years ago.
BIRTH RECORDS UNDER SEAL: Birth records under seal by reason of adoption, paternity determination or court order cannot be
ordered in the usual manner. For a record under seal, write to:
OFFICE OF VITAL STATISTICS
ATTN: Records Amendment Section
P.O. BOX 210
Jacksonville, FL 32231-0042
REQUIREMENT FOR ORDERING: If applicant is self, parent, legal guardian or legal representative, the applicant must provide a
completed application along with valid photo identification, if a mail request, a copy of the valid photo identification must be provided.
If legal guardian, a copy of the appointment orders must be included with the request. If legal representative, the attorney bar
number, and a notation of whom the attorney represents and that person's relationship to the registrant must be included with your
request. If you are an agent of local, state or federal agency requesting a record, indicate in the space provided for “relationship” the
name of the agency. Acceptable forms of identification are the following: Driver’s License, State Identification Card, Passport
and/or Military Identification Card.
If not one of the above, you must complete this application and have a notarized Affidavit to Release A Birth Certificate (DH 1958,
2/03) submitted with your application for the birth record along with a copy of the registrant's valid photo identification as well as the
applicant's valid photo identification.
RELATIONSHIP TO REGISTRANT: A person ordering his or her own certificate should enter "SELF" in this space. Also, explain if
name has been changed; married name, name changed legally (when and where), etc. Others must identify themselves clearly as
eligible (see ELIGIBILITY above).
NONREFUNDABLE: Vital record fees are nonrefundable.
APPLICANT’S SIGNATURE:
Is required, as well as his/her printed name, residence address and telephone number
OPTIONS FOR EXPEDITED SERVICES (only available for mailed applications):
Expedited Processing Fee: If you want to have your application expedited, please mark the outside of your envelope EXPEDITE with the
$10.00 expedited processing fee enclosed. If the record and application are complete and in order, the application will be processed and the
certificate(s) mailed via U.S. Mail by the next business day.
Overnight Delivery Fee:
If you would like to have your certificate(s) returned to you via FedEx (where available, some locations require a
two-day delivery which is determined by FedEx based on delivery address), please include an additional $10.00 Overnight Delivery fee with
your application and $10.00 expedited processing fee, for a total of $20.00. If the record and application are complete and in order, the
application will be processed and the certificate(s) sent via FedEx on the same business day the request was received.
Adult signature is required at time of delivery.
Regular Mail Request: general processing time is 7 to 10 business days for non-expedited mail request.
PAYMENT OPTIONS FOR SERVICES:
Mailing Address:
Florida Department of Health - Volusia County
Mail in request: Checks (starter checks are not accepted) or Money Order
Office of Vital Statistics - Bin #102
payable to Florida Department of Health - Volusia County
P.O. Box 9190
Website: www.volusiahealth.com/certificates
Telephone #:
386-274-0614
Daytona Beach, FL 32120
DH 1960, 4/2016 64V-1.0131, Florida Administrative Code (Obsoletes Previous Editions)