Florida Department of Health in Pasco County
Vital Statistics
SUFFIX
SUFFIX
SEX
SUFFIX
SUFFIX
( )
( )
and THEIR RELATIONSHIP TO REGISTRANT
Fee Quantity Total
The $12.00 fee entitles the applicant to one certification of a registered Birth (1917 - present)
$12.00
1
$ 12.00
Each additional copy of the same certification, when ordered with this request
$8.00
$
Protective Plastic Sleeve, Each
$3.00
$
TOTAL AMOUNT ENCLOSED: Cash (Walk-in ONLY. DO NOT send cash through mail) Visa, MasterCard, Money Order
$
or Cashier's Check payable in U.S. Dollars to Vital Statistics (NO PERSONAL CHECKS)
Complete for Mail-in Request Only: (Must include copy of drivers license of person named on card)
Credit Card Orders: Visa q MasterCard q Name on Card ___________________________________________
Credit Card Number ______________________________________________ Expiration Date __________________
Audit Control #(s)______________________________________ Receipt #___________________________________
MOTHER’S / PARENT'S NAME
HOSPITAL
CITY OR TOWN
PLACE OF BIRTH
LAST NAME PRIOR TO FIRST MARRIAGE
(If applicable)
FIRST
DATE OF BIRTH
MONTH
STATE FILE NUMBER (If known)
IF NAME WAS CHANGED SINCE
BIRTH, INDICATE NEW NAME
CITY
MIDDLE
LAST
YEAR (4 DIGIT)
FIRST
MIDDLE
COUNTY
MIDDLE
RELATIONSHIP TO REGISTRANT
MAILING ADDRESS (INCLUDE APT. NO., IF APPLICABLE)
HOME PHONE NUMBER
FATHER’S / PARENT'S NAME
FIRST
SECTION B: APPLICANT (adult requesting certificate) INFORMATION
SIGNATURE OF APPLICANT
IMPORTANT INFORMATION
Any person who willfully and knowingly provides any false information on a certificate, record or report required by Chapter 382, Florida Statutes, or on any
application or affidavit, or who obtains confidential information from any Vital Record under false or fraudulent purposes, commits a felony of the third
degree, punishable as provided in Chapter 775, Florida Statutes.
FIRST, MIDDLE, LAST (INCLUDING ANY SUFFIX)
Applicant’s Name
TYPE OR PRINT
LAST NAME PRIOR TO FIRST MARRIAGE
(If applicable)
CHILD’S FULL NAME AS SHOWN
ON BIRTH RECORD
APPLICATION FOR A FLORIDA BIRTH RECORD
(County Health Department Use Only)
Read the FRONT AND BACK of this application: Requirement for ordering: If applicant is self, parent, guardian, or legal representative, then
the applicant must complete this application and provide valid photo identification, if a mail request, a copy of the valid photo identification must be
provided. If applicant is not one of the above, the Affidavit to Release a Birth Certificate must be completed by an authorized person and submitted
in addition to this application form. Acceptable forms of identification are the following: Driver’s License, State Identification Card, Passport,
and/or Military Identification Card.
SECTION A: REGISTRANT INFORMATION
FIRST
MIDDLE
LAST
LICENSE/ BAR NUMBER
NAME OF PERSON REPRESENTED
IF ATTORNEY, PROVIDE BAR/PROFESSIONAL
LICENSE NO.
STATE
ZIP CODE
ALTERNATE PHONE NUMBER
13941 15th Street, #212 10841 Little Road
Dade City, FL 33525 New Port Richey, FL 34654
Phone (352) 521-1450 Menu Option 6 Phone (727) 861-5250 Menu Option 6
Fax (727) 484-3867
(M-F 8-4:30 pm)
Fax (727) 484-3867
DH 1960, 04/2016, Florida Administrative Code Rule 64V-1.0131 (Obsoletes Previous Editions)
A computer certification has two different formats:
ELIGIBILITY: Birth certificates can be issued only to:
1. Registrant (the child named on the record) if of legal age (18)
2. Parent(s) listed on the Birth Record
3. Legal guardian (must provide guardianship papers)
4. Legal representative of one of the above persons
5. Other person(s) by court order (must provide recorded or certified copy of court order)
NONREFUNDABLE: Vital record fees are nonrefundable.
REQUIREMENT FOR ORDERING: If applicant is self, parent, legal guardian or legal representative, the applicant must provide a completed
application along with valid photo identification, if a mail request, a copy of the valid photo identification must be provided. If legal guardian, a copy
of the appointment orders must be included with the request. If legal representative, the attorney bar number, and a notation of whom the attorney
represents and that person's relationship to the registrant must be included with your request. If you are an agent of local, state or federal agency
requesting a record, indicate in the space provided for “relationship” the name of the agency. Acceptable forms of identification are the following:
Driver’s License, State Identification Card, Passport and/or Military Identification Card.
If not one of the above, you must complete this application and have a notarized Affidavit to Release A Birth Certificate (DH Form 1958, 08/2010)
submitted with your application for the birth record along with a copy of the registrant's valid photo identification as well as the applicant's valid photo
identification.
RELATIONSHIP TO REGISTRANT: A person ordering his or her own certificate should enter "SELF" in this space. Also, explain if name has been
changed; married name, name changed legally (when and where), etc. Others must identify themselves clearly as eligible (see ELIGIBILITY
above).
APPLICANT’S SIGNATURE: Is required, as well as his/her printed name, residence address and telephone number.
INFORMATION AND INSTRUCTIONS FOR BIRTH RECORD APPLICATION
COMPUTER CERTIFICATION: computer certifications are accepted by all state and federal agencies and used for any type of travel.
1. A certification of a registered birth (2004 to present), supplies the following facts of birth: Child's Name, Date of Birth, Sex, Time, Weight,
Place of Birth (City, County and Location) and Parents' Information.
2. A certification of a registered birth (1930 to 2003), supplies the following facts of birth: Child's Name, Date of Birth, Sex, County of Birth and
Parents' Name.
AVAILABILITY: Birth registration was not required by state law until 1917, but there are some records on file dating back to 1865.
In the case of a deceased registrant, upon receipt of the death certificate of the decedent, a certification of the birth certificate can be issued to the
spouse, child, grandchild, sibling, if of legal age, or to the legal representative of any of these persons as well as to the parent.
Any person of legal age may be issued a certified copy of a birth record (except for those birth records under seal) for a birth event that occurred
over 100 years ago.
BIRTH RECORDS UNDER SEAL: Birth records under seal by reason of adoption, paternity determination or court order cannot be ordered in the
usual manner. For a record under seal, write to:
BUREAU OF VITAL STATISTICS
ATTN: Records Amendment Section
P.O. BOX 210
Jacksonville, FL 32231-0042
DH 1960, 04/2016, Florida Administrative Code Rule 64V-1.0131 (Obsoletes Previous Editions)