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Dl81 VIRGINIA BIRTH CERTIFICATE APPLICATION (Virginia Department of Motor Vehicles)

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DL 81 (09/10/2019)
BORN IN VIRGINIA
VIRGINIA BIRTH CERTIFICATE APPLICATION
Purpose: Customers born in Virginia (from 1912 to the present) use this form to request a Virginia birth certificate in person.
Instructions: The requester - the person submitting this application - must show an acceptable identification document(s) from the list on the back of this form and
provide payment to the Department of Motor Vehicles (DMV). REVIEW PAYMENT INFORMATION on page 2 of this form.
RELATIONSHIP OF REQUESTER TO PERSON NAMED ON THE CERTIFICATE (check one)
REASON FOR REQUESTING
OTHER (specify)
REQUESTER INFORMATION
REQUESTER ADDRESS
REQUESTER NAME (print) - (last) (first) (middle) (suffix)
CITY
ZIP CODE
SELF MOTHER FATHER CHILD CURRENT SPOUSESISTER BROTHER
MATERNAL GRANDPARENT PATERNAL GRANDPARENT LEGAL GUARDIAN -(must show court approved custody papers)
LEGAL REPRESENTATIVE
(additional documents - Bar Card/Power of Attorney required)
TELEPHONE NUMBER REQUESTER EMAIL
RETIREMENT SCHOOL: Pre-K to 12 TRAVEL PASSPORT EMPLOYMENT HOUSING INSURANCE
DMV LICENSE OR ID CARD VETERANS BENEFITS ONLY
STATE
SEX
MALE FEMALE
NON RELATIVE
(Public Record Request only)
PUBLIC RECORD REQUEST - (records at least 100 years old)
NON-IMMEDIATE FAMILY
(Public Record Request only)
CERTIFICATION
I understand that making a false application for a Vital Record is a Felony under state and federal law. I also certify and affirm that all information presented
in this form is true and correct, that any documents I have presented to DMV are genuine, and that the information included in all supporting documentation
is true and accurate. I make this certification and affirmation under penalty of perjury and I understand that knowingly making a false statement or
representation on this form is a criminal violation.
REQUESTER SIGNATURE DATE (mm/dd/yyyy)
FATHER FULL NAME (if known) (print) - (last) (first) (middle) (suffix)
If name has changed since birth
due to adoption, court order or
any reason other than marriage,
enter the changed name here.
BIRTH CERTIFICATE INFORMATION
NUMBER OF COPIES
NAME AT BIRTH (print) - (last) (first) (middle) (suffix)
BIRTH NAME CHANGED TO: (print) (last) (first) (middle) (suffix)
BIRTH PLACE (Virginia city or county)
BIRTH HOSPITAL (optional)
MOTHER FULL MAIDEN NAME (print mother 's name before first marriage/name at time of mother's birth)
(print) - (last) (first) (middle) (suffix)
SEX
MALE FEMALE
BIRTH DATE (mm/dd/yyyy)
DMV USE ONLY
CSR STAMP
DMV CUSTOMER NUMBER
ID Documents Requester Presented (must be 1 primary or 2 secondary documents from the list on the back)
Primary 1 or Secondary 1 Secondary 2
Type of Identification
Expiration Date
Document Number
CSR Signature
( )
DL 81 (09/10/2019)
(The acceptable documents listed may change without prior notice.)
ACCEPTABLE IDENTIFICATION DOCUMENTS
Name: Make sure that your name appears the same on all proof
documents. If your middle name or middle initial begins with the same
letter, but is not spelled out or displayed on all of your documents, your
documents may be accepted. Nicknames will not be accepted. If your
name appears differently on your proof documents, you may be asked
to present additional documentation.
- Documents must be originals. Temporary documents and photocopies will
not be accepted.
- A document will not be accepted when there is reason to believe it has
been altered, fraudulently obtained or is fake, forged, counterfeit, or
otherwise non-genuine or illegitimate. Altering, manufacturing, selling or
possessing a fraudulent birth certificate, driver’s license or ID card,
falsifying information or assisting a person with improperly or fraudulently
obtaining a certification is a criminal offense.
The following is a list of Primary and Secondary documents which are acceptable to the Virginia Department of Health, Division of Vital Records
for the purpose of certifying a birth and/or producing a birth certificate. One Primary Document or two Secondary Documents must be
submitted in order to conduct a certification.
PRIMARY DOCUMENTS
Driver's license issued by a U.S. state, territory, or jurisdiction unexpired or
expired for not more than one year
Learner's/instruction permit issued by a U.S. state, territory, or jurisdiction
unexpired or expired for not more than one year
Photo identification card issued by a U.S. state, territory, or jurisdiction
unexpired or expired for not more than one year
Current Photo ID card, (school and employment with identification number).
Check Cashing Cards are not acceptable
Unexpired U.S. military ID card of an active duty or retired member
U.S. Passport or passport card - unexpired
Unexpired Foreign Passport with VISA, I-94 or I-94W
U.S. Certificate of Naturalization - (form N-550, N-570 or N-578)
U.S. Certificate of Citizenship - (form N-560 or N-561)
U.S. Citizen Identification Card - (form I-197)
Temporary Resident Card - unexpired - (form I-688)
Employment Authorization Card - unexpired - (form I-688A, I-688B or I-766)
Refugee Travel Document - unexpired - (form I-571)
Resident Alien Card - unexpired - (form I-551)
Permanent Resident Card - unexpired - (form I-551)
Northern Marianas Card - unexpired - (form I-551)
Asylum - A copy of the first and last page of application for Asylum
Consular Report of Birth Abroad (form FS-240)
Certificate of Birth Abroad (FS-545)
Certification of Report of Birth of a U.S. Citizen (DS-1350)
Virginia Criminal Justice Agency Offender Information Form
United States Probation Offender Information Form
SECONDARY DOCUMENTS
U.S. Selective Service Card
U.S. military discharge papers (form DD214)
Certified School Records/Transcript issued by a U.S. state or territory
Certificate of Enrollment issued by Virginia Department of Education
Life insurance policy
Health care insurance card - (i.e. Medicare Card/ Medicaid Card)
Unexpired welfare/social services identification card with photo, issued by
a municipality
State-issued driver's license or learner's/instruction permit, with photo,
expired not more than 5 years
State-issued photo identification card expired not more than 5 years
U.S. Passport or passport card - expired not more than 5 years
Unexpired military dependent ID card, with photo
Foreign Passport - expired not more than 5 years, with a U.S. VISA ·
Unexpired weapons or gun permit issued by federal, state or municipal
government
Unexpired pilot's license
Veterans' Universal Access Identification Card
INS form I-797 (applicable only for individuals whose names appear on
the form)
USCIS student or dependent SEVIS I-20 with or without USCIS stamp
(Applicant's name must appear on the form)
U.S. Department of State form DS-2019 (Applicant's name must appear
on the form)
Fees paid for a birth certificate/vital records search are non-refundable. Virginia statutes require DMV to charge a fee of $14.00 (which includes a $2.00
administrative fee) for each search regardless of whether a certification of a vital record is completed or not found.
PAYING BY CHECK?
WHILE IN A DMV CUSTOMER SERVICE CENTER - make check payable to the Department of Motor Vehicles (DMV). There is an $85.00 service charge
for returned checks. Requests that cannot be completed by DMV will be forwarded to the Virginia Department of Health/Division of Vital Records. The
State Registrar of Vital Records reserves the right to accept or deny any application (Virginia Code §32.1-271 (C)).
REQUESTING BIRTH CERTIFICATE BY MAIL - This form may be used only by persons while in a DMV Customer Service Center. To obtain a birth
certificate by mail, download the Virginia Department of Health's "Application for Certification of a Vital Record", www.vdh.virginia.gov. Mail that completed
application to: Division of Vital Records, P.O. Box 1000, Richmond, VA 23218-1000.
PAYMENT INFORMATION
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Completed 30 July 2020

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