Application for a
Birth Certificate
BIRTH
PART 1: APPLICANT
State:
Email address:
(Middle) (Last)
(Su
x)
PART 2: BIRTH CERTIFICATE BEING REQUESTED
NAME AT BIRTH
AGE NOW DATE OF BIRTH
(First) (Middle) (Last) (Sux)
If name has changed since birth due to adoption, court order or any reason other than marriage, please list
that name here:
(First)
(Middle) (Last) (Sux)
PARENT/MOTHER'S NAME
(First) (Middle) (Last name prior to first marriage)
(Sux)
PARENT/FATHER'S NAME
(First) (Middle)
(Sux)
(Current last)
(Current last)
PART 3: ACCEPTABLE FORMS OF IDENTIFICATION
I have included a legible photocopy of one of the following:
HOW TO APPLY
(Signature)
(Date)
Signature must agree with the name listed in Part 1 of this form.
PART 5: SIGNATURE OF APPLICANT
By my signature below, I state I am the person whom I represent
myself to be herein, and I affirm the information within this form is
complete and accurate and made subject to the penalties of 18
Pa.C.S.§4904 relating to unsworn falsification to authorities. In
addition, I acknowledge that misstating my identity or assuming the
identity of another person may subject me to misdemeanor or
felony criminal penalties for identity theft pursuant to 18
Pa.C.S.§4120 or other sections of the Pennsylvania Crimes Code.
Department of Health
Division of Vital Records
PO Box 1528
New Castle, PA 16103
(Last name prior to first marriage)
H105.102 REV 06/18
INTERNAL USE ONLY
SEX
Female
Male
TYPE OF BIRTH RECORD
(City/borough/township)
(County)
(Hospital name)
A valid driver's license or other government-issued photo ID that
includes my mailing address. If applying by mail, the address on
my ID matches the mailing address listed above. Expired IDs
cannot be accepted.
I do not have a valid government-issued photo ID. Therefore, I
have provided two current documents that verify my name and
current address (such as a utility bill, pay stub, bank statement,
car registration or lease/rental agreement). See
www.health.pa.gov/MyRecords/Certificates for further
information.
PART 4: FEE
Certificate cost:
Quantity:
Total:
Armed forces member name:
Service number:
Rank and branch of service:
Make check or money order
payable to "VITAL RECORDS."
$20
.00
Social Security/benefits
School
Employment
Driver’s license
(Please specify other reason.)
Travel/passport
Dual citizenship
Other:
Please complete as much information as possible.
Zip code:
Fee waiver Request — member of the U.S. armed forces
The fee is waived if the applicant is requesting the certificate for self,
spouse or a dependent child.
Order from Pa.’s only authorized online provider at www.vitalchek.com
or by phone at 866-712-8238 (credit cards accepted).
Order in person at a Pennsylvania Vital Records branch office in Erie,
Harrisburg, New Castle, Philadelphia, Pittsburgh or Scranton. Delivery
ranges from same day to five days based on public office processing time.
Order by mail: Send application, identification and payment to:
Daytime phone:
(First)
My current legal name:
Street:
City:
MY RELATIONSHIP TO PERSON NAMED ON BIRTH RECORD
:
X
Print or Type
PLACE OF BIRTH
I am or my current legal spouse (includes widow/widower if not
remarried) is in active service or was honorably discharged from service.
Applicants must be 18 years of age or
older or an emancipated minor to apply.
Intended use of birth certificate:
Initials:
Date:
Delivery:
Initials:
Date:
Delivery:
P
S R A
PO
M
