Fillable Application to Town Clerk for Copy of Birth (Town of Brookhaven)

Fill Online, Printable, Fillable, Blank Application to Town Clerk for Copy of Birth (Town of Brookhaven) Form

Use Fill to complete blank online TOWN OF BROOKHAVEN (NY) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Application to Town Clerk for Copy of Birth (Town of Brookhaven)

On average this form takes 11 minutes to complete

The Application to Town Clerk for Copy of Birth (Town of Brookhaven) form is 2 pages long and contains:

  • 0 signatures
  • 13 check-boxes
  • 36 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Town of Brookhaven

BROWSE TOWN OF BROOKHAVEN (NY) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Application to Town Clerk
for Copy of Birth Certificate
TC-01 rev. 06/20
TC-01 Page 1of 2
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738 (631)
451-9101 FAX: 451-9264
BIRTH CERTIFICATES
The Brookhaven Town Clerk’s Office maintains birth records for individuals born in the Town of Brook
haven, including
births that occurred in Port Jefferson through December 31, 1963, and in the Villages of Lake Grove and Mastic Beach to
the present. Any births that occurred in the Village of Port Jefferson from January 1, 1964 through the present are on file
with the Village Clerk of Port Jefferson (631) 473-4724.
The only individuals eligible to obtain a birth certificate include:
The person named on the certificate.
A parent of the person named on the birth certificate is always
entitled to a child’s birth certificate
(requesting parent’s name must be on birth certificate).
A person who has court-ordered legal custody/guardianship of the minor child listed on the birth
certificate. If the applicant has legal custody/guardianship, a certified copy of the court order must
accompany the request.
An individual who has notarized authorization from the person named on the certificate (if 18 years of
age or older) or either parent listed on the record. If the applicant has notarized authorization to obtain the
record on behalf of an eligible individual, the original notarized statement must accompany the request.
Identification Require
ments: Applications must be submitted with copies of either A OR B*:
A. One (1) of the following forms of valid photo ID:
Driver’s License
DMV issued Non-Driver Photo ID
Passport
US Military ID
Naturalization Papers
Permanent Resident Card
Employee photo ID plus a pay stub from current employer
Police report of lost/stolen ID
B. Two (2) of the following showing applicant’s name and address:
Utility or telephone bills dated within the last six (6) months
Letter from a government agency dated within the last (6) months
Pay stubs dated within the last six (6) months
*If the applicant’s name on the ID differs from the information on the birth certificat
e, a copy of the applicant’s
marriage ce
rtificate, legal name change paperwork, citizenship papers or naturalization papers mu
st accompany
the request.
ANY REQUESTS FOR A BIRTH CERTIFICATE TO BE MAILED TO A POST OFFICE BOX OR TO A THIRD
PARTY MUST BE NOTARIZED.
Fee: $10.00 per certified copy requested. No more than two (2) copies will be issued within a twelve-month period.
Payment may be made by check or money order payable to “Donna Lent, Brookhaven Town Clerk”.
Application to Town Clerk
for Copy of Birth Certificate
TC-01 rev. 06/20
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
TC-01 Page 2of 2
Applicants should mail the completed application to the Brookhaven Town Clerk (see attached instructions for additional
information or visit www.brookhavenny.gov).
Required ID and fee must be included with application. No more than two (2)
copies of a Birth Certificate will be issued within a 12-month period. Make check or money order payable to Donna Lent,
Brookhaven Town Clerk. Fee: $10 per copy or No Record Certification. Please do not send cash or stamps.
CERTIFICATE INFORMATION
1. Name (as listed on Birth Certificate):
First Middle Last
2. Date of Birth
M M D D Y Y Y Y
3. Place of Birth: Hospital (if not hospital, give street and number)
4. Village, Town or City 5. County
6. Father/Parent’s Birth Name:
First Middle Last
8. Birth Certificate No.: (if known)
9. Local Registration No.: (if known)
7. Mother/Parent’s Birth Name:
First Middle Last
10. No. of Copies
Requested:
11. Amount Enclosed:
12. Purpose for which Record is Required: (Check One)
Passport Employment Driver’s License Veteran’s Benefit
Social Security Working Papers Marriage License Court Proceeding
Retirement School Entrance Welfare Assistance Entrance into Armed Forces
Other, Please Specify: ____________________________________
APPLICANT INFORMATION
13. Name:
First Middle Last
14. Telephone:
( )
15. What is your relationship to the person
whose record is required?:
(If self, state “SELF”)
16. If attorney, give name and relationship of your client to person whose record is
required:
Name of Client Relationship
17. Address of Applicant: 18. Name and Address Where Record Should Be Sent: (If delivery is to a
P.O. Box or third party, you must submit with this application a notarized
statement signed by the applicant stating such.)
19. Signature of Applicant: 20. Date:
This office requires written authorization of the person/parents whose record is requested.
TYPES OF ACCEPTABLE IDENTIFICATION:
1. Valid Driver’s License
2. Valid State-Issued Non-Driver’s License
3. Passport
4. Naturalization Papers
5. Military
ID
6. Employer’s Photo ID with Pay Stub
7. Two Utility Bills Showing Applicant’s Name and Address
8. Police Report of Lost or Stolen ID
FOR REGISTRAR USE ONLY
DO NOT ISSUE COPY UNLESS ONE OF TYPES OF ID IS
PRESENTED. Photocopy of ID and attach to application form.
Type of ID:
Driver’s License: State No.
Other ID, specify:
No.:
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Application to Town Clerk for Copy of Birth (Town of Brookhaven)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 12 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document