Fillable APPLICATION FOR CERTIFIED MISSISSIPPI BIRTH CERTIFICATE (Mississippi)

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APPLICATION FOR CERTIFIED MISSISSIPPI BIRTH CERTIFICATE (Mississippi)

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Mississippi State Department of Health Revised 01/2017 Form No. 522
APPLICATION FOR CERTIFIED MISSISSIPPI BIRTH CERTIFICATE
Mississippi State Department of Health
Vital Records
Post Office Box 1700, Jackson, Mississippi 39215-1700
FULL NAME ON
BIRTH RECORD
FIRST
MIDDLE
LAST
HAS NAME CHANGED
SINCE BIRTH? □ Yes □ No
If so, what was original name?
DATE OF
BIRTH
DAY
YEAR (4 digit)
STATE FILE NUMBER IF KNOWN
PLACE OF
BIRTH
COUNTY
CITY
STATE
SEX
□ MALE □ FEMALE
RACE
NAME/LAST NAME
MOTHER OR PARENT
FIRST
MIDDLE
LAST (MAIDEN)
NAME/LAST NAME
FATHER OR PARENT
FIRST
MIDDLE
LAST (MAIDEN)
PERSON REQUESTING CERTIFIED COPY
RELATIONSHIP TO APPLICANT
PURPOSE FOR WHICH NEEDED
SIGNATURE OF APPLICANT
DATE
A BIRTH RECORD SEARCH REQUIRES ADVANCE PAYMENT OF A NON REFUNDABLE SEARCH FEE OF $17.00 AND VALID PHOTO IDENTIFICATION.
Pursuant to Section 41-57-2 of the Mississippi Code of 1972, Annotated and as defined by Mississippi State Board of Health Rules and Regulations only
person having legitimate and tangible interest in a birth certificate is entitled to obtain a copy. Anyone obtaining a copy of a birth certificate under false
pretenses is subject to the penalties as described in Section 41-57-27 of the Mississippi Code.
The $17.00 fee entitles the applicant to one certified copy of the birth
record on file of if the record is not found a “Not on File” statement $ 17.00 X 1 = $17.00
will be issued.
Additional Certified copies of the same record ordered at the same.
$6.00 for each additional certified copy. $ 6.00 X =
Amt.
No. of copies Enclosed
TOTAL AMOUNT ENCLOSED. Check (personalized with name, address,
and bank branch name and address printed on check) or Money Order payable to
Mississippi Vital Records. Mississippi law allows an additional service TOTALS
charge for dishonored checks. (DO NOT SEND CASH)
PHOTO IDENTIFICATION REQUIRED
Failure to provide the proper identification will result in the application being returned to you without processing. Acceptable forms
of identification are: Valid Driver’s License, State Issued Identification Card, Passport, and/or Military Identification Card,
Valid School , College or University Identification. (See back for other acceptable forms.).
MAILING ADDRESS REQUIRED REGARDLESS OF DELIVERY METHOD
Applicant Name
(Type or Print)
Delivery Address
(include APT number)
City
State
Phone Number, including area code
DO NOT WRITE IN THE SPACES BELOW – FOR OFFICE USE ONLY
12 –36
S.C.
SUP.
37 – 66
S.C.
P.
$0.00
1
$17.00
Mississippi State Department of Health Revised 01/2017 Form No. 522
INFORMATION AND INSTRUCTIONS FOR BIRTH RECORD APPLICATION
Eligibility: A certified copy of a birth certificate can be issued only to a person with legitimate and tangible
interest as defined by the Rules Governing the Registration and Certification of Vital Events.
Primarily this is:
1) Registrant (the child named on the record), if of legal age.
2) Parent(s) listed on the birth record, if VR office has not been notified of termination of parental rights.
3) Spouse, sibling(s), or grandparent(s)/child(ren) of registrant
4) Legal Guardian, guardianship papers must be provided.
5) Legal representative of one of the above persons, proof of representation must be provided.
6) Licensed adoption agencies working within the statutory authority of §93-17-205.
7) Other person(s) by court order, certified copy of court order must be provided.
For Genealogy purposes - Genealogy must be stated as purpose for certificate. Relationship to applicant must be
provided. Plain paper copies are provided for genealogy purposes.
Requirements for Ordering: If applicant is self, spouse, parent, grandparent, sibling, child, grandchild, guardian, or legal
representative, then the applicant must provide a completed application and a copy of a valid photo identification of
the applicant. Acceptable forms of identification are the following:
+ Photo Driver’s License
+ Photo State Issued ID
+ Employment ID
+ School, College or University ID
+ US Military ID
+ Tribal ID
+ Alien Registration/Permanent Resident Card
+ Temporary Resident Card
+ US Passport
OR two forms of identification from the following list:
+ Social Security Card
+ Utility Bill (showing address)
+ Medicaid Card
+ Snap/EBT card (showing address)
+ Work Identification
+ Veteran Universal Access ID Card
Guardian or legal representative must submit proof of guardianship/legal representation with this application. Legal
representatives must provide attorney bar number, name of person represented, and their relationship to the
registrant. 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. If you do not have one of the above referenced documents, please contact
Vital Records at 601-206-8200.
Relationship to Applicant: A person ordering his or her own certificate should enter “SELF” in this space. Also, explain if name has
been changed by marriage, legal name change (when and where), etc. Others must identify their relationship to the
registrant clearly. For genealogy, relationship to applicant must be provided.
Nonrefundable: Vital record fees are nonrefundable, with the exception of fees paid for additional copies when no record is found.
Failure to Receive: Complaints of failure to receive certified records will be honored within 6 months of the original request. Please
allow three (3) weeks after mailing the request to make inquires to this office. Inquiries about copies ordered with
payment for special courier delivery should be made within 7 days of the request. Mail returned because of
insufficient address will be re-mailed if this office is notified of correct address within 6 months of request.
Options for Service: Certified copies of birth records may be ordered in person, by mail, or, if paying by credit card, online or by
telephone. Processing time is generally 7 – 10 working days after receipt of request. If amendment action is
necessary, additional processing time will be required. Payment of fees is required at the time of ordering.
• WALK-IN SERVICE is available at 222 Marketridge Dr., Ridgeland, MS between the hours of 8:00 am and 4:30 pm. Most
records will be available while you wait; some require special processing and will be mailed within 7 - 10 days of the request.
• MAIL-IN requests, either on the form provided or as a free form request will be processed in the order received and will be
returned by regular U.S. Postal Service, unless accompanied by a prepaid special courier self-addressed envelope.
• PAYMENT BY CREDIT CARD can be completed by using an online service or by telephone. The private company
approved to handle credit card transactions for Mississippi birth records can be accessed by calling 1-877-295-4229 or by
visiting www.msdh.state.ms.us/phs and clicking on link for online ordering. If you have questions or need additional
assistance call 601-206-8200. A recorded message outlining ordering requirements and options can be accessed by dialing
601-206-8200, option 1.
MAIL THIS APPLICATION WITH PAYMENT AND COPY OF IDENTIFICATION TO:
MISSISSIPPI VITAL RECORDS
P.O. BOX 1700
JACKSON, MS 39215-1700
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Completed 27 August 2020

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