DHHS-VR-B (Revised 12/2018)
N.C. Vital Records
PLEASE PRINT
Application for a Copy of a North Carolina Birth Certicate
Full Name on Certicate
(If adopted, provide new information)
_________________________________________________________________
Date of Birth ____ | ____ | ________
Month Day Year
Sex Male Female
Were parents married
at time of birth? Yes No
Is this person deceased? Yes No
Place of Birth _________________________________________
City County
Full Name of Mother/Parent
(Adoptive parent, if applies)
___________________________________________________________________
First Name Middle Name Last Name Last Name prior to rst marriage, if applies
Full Name of Father/Parent
(Adoptive parent, if applies)
___________________________________________________________________
First Name Middle Name Last Name Last Name prior to rst marriage, if applies
Check all boxes that apply; add the fees in 1–3
and place the total amount in #4.
See further instructions on Page 2.
Your Relationship to the Person Whose Certicate is Requested:
(Check One)
1. Order Certicate
Processing times vary.
Check website for current information.
(Non-refundable fee)
Certicate Search and First Copy ($24) $ ______
#____ additional copies x $15 $ ______
Certied
(Suitable for legal purposes)
Uncertied
(Not suitable for legal purposes)
Self
Spouse (Current)
Brother/Sister
Child/Stepchild
Parent/Stepparent
Grandparent
Grandchild
Authorized agent, attorney or legal representative of
the person listed (Proof REQUIRED)
Other (may not be entitled to a certied copy)
Specify:
(Please Print)
Requestor
: ______________________________________________________________
Print Name of Person Requesting the Certicate
Address: ______________________________________________________________
Street Address (P.O. Box cannot be used for expedited shipping)
_________________________________________________________________________
P.O. Box (If mailing to a P.O. Box, street address must also be listed above)
_________________________________________________________________________
City, State and Zip Code
_________________________________________________________________________
(Area Code) Telephone Number (During business hours)
Email Address: ___________________________________________________________
Payment: Please pay with a cashier’s check or money order made payable to N.C. Vital
Records. Personal checks are not accepted. Requests that are submitted with no payment
or incomplete payment or incomplete information will be returned. Credit card payment is
available for walk-in customers.
IDENTIFICATION OF THE PERSON REQUESTING A CERTIFICATE
IS REQUIRED.
See Page 2 for a list of acceptable IDs.
2. Record Changes (Only if applies)
Appointment required for in-person services.
($15 non-refundable processing fee)
Adoption $ ______
Amendment $ ______
Name Change $ ______
Legitimation Court Order $ ______
Legitimation (mother married father
after child’s birth) $ ______
Paternity (no fee) $
0.00
Other _____________________ $ ______
3. Faster Service (Choose only one)
Optional for mail-in requests - Must write “Expedite”
on the outside of the envelope.
($15 non-refundable expedite fee)
Walk-in Service ($15) $ ______
Expedited Processing ($15) $ ______
(Shipped by regular mail)
Expedited Processing and
Expedited Shipping ($35) $ ______
(Call for expedited shipping fees outside the continental United States)
4. Total Fees
(Add 1+2+3 above for total) $ ______
I hereby certify that all the above information is true to the best of my knowledge. Note: It is a felony violation of North Carolina Law (G.S.
130A-26A) to make a false statement on this application or to unlawfully obtain a copy or a certied copy of a birth certicate.
___________________________________________________________ ______________________________________________
Signature of Person Requesting the Certicate Date Signed
Ofce Use Only: SFN _______________________________ DCN _____________________________ Cartridge/Frame _______________________________________
Amount received: $_______________________ Identication presented_______________________________________________________________________________
Request number ___________________________________________ Request date _____________________________________________________________________
— — — — — — CUSTOMER MUST COMPLETE — — — — — —
How do you plan to use this record?
First Name Middle Name Last Name
North Carolina Department of Health and Human Services
Division of Public Health • N.C. Vital Records
https://vitalrecords.nc.gov
Telephone: 919-733-3000
Mail: 1903 Mail Service Center
Raleigh, NC 27699-1900
Location: 225 North McDowell St.
Raleigh, NC 27603-1382
