Page 1 of 2 OFFICE OF VITAL RECORDS
07/2019
Birth Certificate Application
Complete this form to order a certified copy of a Minnesota birth certificate.
You are required to provide the information requested on this form and pay the required fees to obtain a birth certificate.
If we cannot locate the record with the information you provide, we will send you a certified “Statement of No Birth Record Found”.
It is unlawful to provide false information to get a birth certificate. You may be subject to fines, jail time or both.
Minnesota Statutes, section 144.227 and section 609.02, subdivisions 3 and 4.
A. Information to locate the requested birth record
Minnesota Rules, part 4601.2600, subpart 2
Child/Subject
Child/subject first name Child/subject middle name Child/subject last name Name suffix
Date of birth (MM/DD/YYYY)
Sex
☐ Female
☐
Male
Minnesota city of birth Minnesota county of birth State of birth
MN
Parents
Parent one first name Parent one middle name Parent one last name Last name before 1
st
marriage Name suffix
Parent two first name Parent two middle name Parent two last name Last name before 1
st
marriage Name suffix
B. Requester - person completing this application
Minnesota Rules, part 4601.2600, subpart 3
Requester
Requester full name Date of birth (MM/DD/YYYY)
Daytime phone (XXX-XXX-XXXX)
Requester mailing address – street
(United Parcel Service (UPS) will not deliver to PO boxes or APO addresses.)
Apt/Unit # Email
City State ZIP
Marital status is important.
Records of children born to married parents are “public”. That means that the certificate is available to those listed in items 1 – 19 below.
Records of children born to single mothers are “confidential” unless the mother chooses to make the record public at the time of birth. Confidential
birth certificates are restricted to the persons listed below in items 20 – 24. Minnesota Statutes, sect
ion 144.225, subdivisions 2 and 7.
C. MANDATORY — Check the boxes below that describe your relationship to the subject of the record:
Birth certificates available to individuals who meet any of the legal requirements in items 1-19 below (Public records)
1. ☐ A parent named on the subject’s record 2. ☐ A grandparent of the subject 3. ☐ A great–grandparent of the subject
4. ☐ A child of the subject 5. ☐ A grandchild of the subject 6. ☐ A great-grandchild of the subject
7. ☐ Spouse of the subject (You must be the current spouse) 8. ☐ I am requesting my own birth record
9. ☐ Party responsible for filing the record (generally a health professional or birth attendant)
10. ☐ The legal custodian, guardian or conservator of the subject (a certified copy of a court order naming you is required)
11. ☐ The health care agent for the subject (health care power of attorney is required)
12. ☐ Subject’s personal representative; a certified copy is needed to administer the estate
13. ☐ Successor of the subject (subject is dead); the certified copy is needed to administer the estate
14. ☐ Determination or protection of a personal or property right and proof that birth certificate is needed
15. ☐ Adoption agency — to complete post-adoption search (Employee ID is required)
16. ☐ Local/state/tribal or federal governmental agency (Employee ID is required)
17. ☐ Attorney – my Minnesota Attorney License Number is:_________________ NON-Minnesota license? Affix copy
18. ☐ Pursuant to a valid, certified copy of a U.S. court order (not a subpoena) releasing the certificate
19. ☐ I have a signed statement from a person above; it specifies the subject’s full name, date of birth, parents’ names, the signer’s
relationship to the subject of the record and it authorizes me to obtain the certificate.
Birth certificates available only under the conditions or to the persons named below (Confidential records)
20. ☐ Parent named on the subject’s record
21. ☐ The legal custodian, guardian or conservator of the subject (a certified copy of a court order naming you is required)
22. ☐ The subject, when 16 years or older
23. ☐ Representatives of Minnesota programs that administer child support, medical assistance, MinnesotaCare, and services under
Minnesota Statutes, sections 124D.23 and 626.556, and tribal child support programs, Minnesota Statutes, section 144.225,
subdivision 2, paragraph (f). (Employee ID is required)
24. ☐ Pursuant to a valid, certified copy of a U.S. court order (not a subpoena) releasing the certificate
