REQUEST FOR A CERTIFIED COPY OF A BIRTH OR DEATH CERTIFICATE
Choose one (1) primary document or two (2) alternate documents that you are providing with this request.
☐ U.S. issued Driver’s License or ID Card
☐ U.S. Territories Driver’s License or ID Card
☐ Tribal ID Card containing your signature
☐ U.S. Military ID Card containing your signature
☐ Passport: U.S. or Foreign issued
☐ VISA: U.S. issued and included within a Passport
containing your signature
☐ U.S. Resident Alien Card or U.S. Green Card or
U.S. Permanent Resident Card (Form I-551)
☐ U.S. Employment Authorization Document or
Card (Form I-765)
Document # ________________________________
Expiration Date: __ __/__ __/__ __ __ __
These two documents together must contain your
current address and your signature.
☐ Employment Photo ID Card with a Pay Stub or
U.S. Internal Revenue W-2 form
☐ School, University or College Photo ID with
Report Card or other proof of current enrollment
☐ Department of Corrections ID Card with
probation documents or discharge papers
☐ Social Security or Medicare Card with your
☐ Pilot’s License
☐ Car Registration or Title with current address
☐ U.S. Selective Service Card
☐ Voter’s Registration Card
☐ Filed Federal Tax Form with current address and
☐ Bank Statement or Utility Bill (gas, water,
electric, sewer, phone) with current address
☐ U.S. or State Court documents with current
Total Number of Copies Requested: ______ x $10.00 each = Order Total: $ __________________
Make checks or money orders (U.S. funds) payable to __________________________________. Mail your
payment with this form and a self-addressed envelope to _______________________________________.
Or bring this completed form with your payment to _____________________________________________.
Any person who knowingly makes a false statement, misrepresentation or certification as to any material
fact on this application shall be fined not more than $10,000 or imprisoned for not more than six months or
both. 18 V.S.A. § 131(c).
I certify that the information provided on this form is true and I am eligible to receive a certified copy.
Signature*: ______________________________________________ Date Signed*: __ __/__ __/__ __ __ __
FOR OFFICE USE ONLY:
ID checked and validated by: Date:
CID: CPA-B: CPA-E: Fee enclosed: $ Check Number: