Fillable Form 20210401: N . 2021-2022 i BIRTH Application (Québec)

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Form 20210401: N . 2021-2022 i BIRTH Application (Québec)

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The Form 20210401: N . 2021-2022 i BIRTH Application (Québec) form is 5 pages long and contains:

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Country of origin: CANADA
File type: PDF

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Accelerated processing − Enter the number of documents requested.
Normal processing − Enter the number of documents requested.
X
Applicant’s mandatory signature
I solemnly declare that, to the best of my knowledge, the information provided is accurate and that I have the right to obtain the
documents requested.
33. Date 32.
Year
Month Day
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Section 4: Applicant’s declaration
5. Province
11. Does the application concern someone who is deceased?
Extension 9. Area code Phone number (other) 8. Area code Phone number (home)
10. If your application concerns someone other than yourself or your child, give the
reason for your application and attach a photocopy of an official document as proof.
2. Applicant’s given name 1. Applicant’s surname
4. City, town, village or municipality 3. Home address (number, street) Apartment
Section 1: Information on the applicant
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7. Country 6. Postal code
16. Date of birth
Year Month Day
15. Sex
18. Place of registration of birth if it occurred before 1994
(parish, place of worship, city, town, village or municipality)
17. Place of birth (city, town, village or municipality, province or country, if abroad)
14. Other given names (separated by commas)
13. Usual given name 12. Surname
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Section 2: Information on the person concerned by the application
BIRTH
N
FO−11−13
20210401
Ministère du Travail, de l’Emploi et de la Solidarité sociale
Application for a Certificate or Copy of an Act
2021-2022
Version
26. Subtotal (boxes 23 to 25)
23. Short−form certificate 25. Copy of an act
=
24. Long−form certificate − Recommended
+
$
+
You can mail your application or submit it at a service counter. The cost varies accordingly. The documents you order will be sent to you
by mail.
31.
Total: $
Section 3: Documents requested − The following fees are in effect until March 31, 2022.
30. Subtotal (boxes 27 to 29)
27. Short−form certificate
29. Copy of an act
$76.75 (at a counter)
$71.75 (by mail)
x=
=
28. Long−form certificate − Recommended
+
$
+
$
$76.75 (at a counter)
$71.75 (by mail)
x=
$
$76.75 (at a counter)
$71.75 (by mail)
x=
$54.25 (at a counter)
$48.25 (by mail)
=
$54.25 (at a counter)
$48.25 (by mail)
x=
$60.25 (at a counter)
$56.25 (by mail)
x=
i
$
$
$ $
Add the amounts in boxes 26 and 30 to determine the amount payable.
Detach here.
In effect until
March 31, 2022
19. Surname and given name of parent
21. Surname and given name of the other parent
Parents
Father Mother
20. Capacity of parent
Father Mother
22. Capacity of parent
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Yes No
Male Female
This pictogram refers you to page
4 of the general information and
instructions.
i
x
I authorize the Directeur de l’état civil to charge the amount
entered in Box 31 to my credit card.
Expiry
Date
X
Cardholder’s mandatory signature
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35. Credit card
34.
Cash
(at a service counter)
Debit card
(at a service counter)
}
Payable to
Directeur de l’état civil
Section 5: Methods of payment
Credit card number
Year
Month
Postal or bank money order
Cheque
TO THE APPLICANT
.
.
Read the general information and instructions.
Complete all sections of the form in block letters (uppercase, lowercase, accented characters), in black
or blue indelible ink.
Include the payment and two photocopies of documents issued by two separate organizations
that will allow us to establish your identity, i.e. a photocopy of a valid photo ID and a photocopy
of a valid proof of home address.
Sign and date Section 4.
.
.
x $48.25 (by mail)
x $48.25 (by mail)
x $56.25 (by mail)
x $71.75 (by mail)
x $71.75 (by mail)
x $71.75 (by mail)
x $54.25 (at a counter)
x $54.25 (at a counter)
x $60.25 (at a counter)
x $76.75 (at a counter)
x $76.75 (at a counter)
The application must be signed and dated.
x $76.75 (at a counter)
Before starting
0.00
If you are paying by credit card, the cardholder must sign the form.
Certificates and copies of an act for each of these events are obtained by using the corresponding form.
Ensure that you have a version of the form that is up−to−date in order to avoid any delay in processing your application.
The version of the form is indicated in the upper right−hand corner, next to its title.
The forms are available on our website, at our service counters and at Services Québec offices, or by contacting us.
You can submit your application using one of our online services, at www.etatcivil.gouv.qc.ca. In doing so, you will pay a lesser fee for
your documents, as well as avoid postal delivery times.
Certificates and copies of acts are official and distinct documents issued by the Directeur de l’état civil relating to births, marriages, civil unions
or deaths entered in the Québec register of civil status.
These documents show the information that appears in the original act, exactly as entered and spelled in the register, and not the
information provided in the Application for a Certificate or a Copy of an Act. Moreover, certificates and copies of acts are issued in the
same language that the event was registered.
Application for a certificate or copy of an act of birth, marriage, civil union or death
Entering a civil status event in the register
It is important to point out that, for a civil status document to be issued regarding a birth, it must first be entered in the Québec register of civil
status. An application for a certificate or copy of an act, or an attestation for that event can be processed only once registration is completed.
To find out the time limit for entering an event in the register, see our website or contact us.
Cancelling or modifying an Application for a Certificate or Copy of an Act
An Application for a Certificate or Copy of an Act cannot be cancelled or modified.
The information gathered on this form is used solely to process
your application. Failure to provide this information may result in
delay or the refusal of your application. Only our authorized
personnel can access this information.
You can consult your personal information and correct it within the
prescribed legal framework. This personal information is shared with other
organizations only where permitted by law.
You can consult your personal information and correct it within the
prescribed legal framework. This personal information is shared with other
organizations only where permitted by law.
To ensure that my application will be processed
without additional delay:
I have completed all sections of the form.
I have attached a legible photocopy of a valid photo ID.
I have attached a legible photocopy of a valid proof
of home address.
I have signed and dated Section 4.
I have included the payment corresponding to the type
of processing selected.
I have ensured that the documents requested are
the ones I require.
I have completed the form in block letters (uppercase,
lowercase, accented characters), in black or blue
indelible ink.
Checklist
Use DEClic! or DEClic! Express (certain conditions apply) to apply for a
certificate or a copy of an act online. You will pay a lesser fee for such
documents as compared to an application sent by mail. Try it!
Save up by filing your application online!
Please visit our website at www.etatcivil.gouv.qc.ca for information
about our services, to download our forms or to access our online
services.
Website and online services
Protection of personal information
A parent mentioned in his or her child´s act of birth may apply for a birth certificate or a copy of the act of birth regardless of the child’s age.
If the application concerns someone other than yourself or your child
If the application concerns someone other than yourself or your child, your name will not appear in the act in question. You must therefore
establish your interest by providing a reason supported by a document, as per the instructions on page 4. The Directeur de l’état civil will
assess the reason given.
If the application concerns a minor child
Since the applicant must submit documents that a minor child may not be able to provide, it is recommended that one of the parents act as
applicant on the child’s behalf.
To protect the identity of the persons entered in the Québec civil status register, a birth certificate or copy of an act of birth can only be issued
to persons mentioned in the act in question or to those who establish their interest.
The applicant is the person who requests the certificate or copy of an act of birth.
If the application concerns someone who is deceased
If the application concerns someone who is deceased, the certificate or copy of the act may be issued to the deceased’s spouse (by marriage
or civil union), son or daughter, or brother or sister, even if they are not mentioned in the act, without having to provide a document supporting
the reason given. However, as per the instructions on page 4, they must allow the Directeur de l’état civil to validate their relationship with the
deceased.
Lawyers and notaries
If you are a lawyer or notary and are completing an application on behalf of your client, you must enter your member number following your
surname in Box 1 of the form, as well as your client’s file number in Box 10 of the form.
Who can be the applicant?
What should you know?
1 de 4
Ministère du Travail, de l’Emploi et de la Solidarité sociale
Naissance FO−11−13 (2021−04−01)
Do not return this document with your application.
General Information and Instructions
for an Application for a Certificate or Copy of an Act
Return to form
$71.75
$71.75
$65.75 $65.75
$76.75 $76.75
$65.75 $65.75
Cost per
certificate
Cost per
copy of an act
$41.00
$60.25
$41.00
$56.25
$33.75
$48.25
$54.25
$33.75
Cost per
certificate
Cost per
copy of an act
* Excluding event registration time (if recent event) and delivery time.
The amounts are in Canadian dollars and are in effect until March 31, 2022.
Online
At a service counter using the DEClic! Comptoir
online service
By mail
At a service counter
Method used to file your application
Fees and processing time *
Application for normal
processing (10 business days) *
Also factor in the time needed to
enter a recent civil status event in
the register.
Application for accelerated
processing (3 business days) *
Also factor in the time needed to
enter a recent civil status event in
the register.
Processing time to register a civil status event in the register
The processing time to enter a new event in the register varies according to the number of events to be entered and the complexity of the files.
For information on the processing time needed to enter an event in the register, see our website or contact us.
The fee charged to issue a document varies according to how the application is submitted and the type of processing selected. We offer
normal and accelerated processing.
Fees and processing time
If you choose normal processing, the document will be sent by regular mail. If you choose accelerated processing, the document will be
mailed to you via Xpresspost (available only if the delivery address is in Canada).
30−minute issuance service
It is possible to order and receive a certificate or a copy of an act of birth in 30 minutes, provided your file meets certain conditions. This
service is available only at our service counters in Québec and Montréal.
What payment methods are accepted?
Multiple applications
If you are submitting more than one application form at a time, please
send a separate payment with each form to speed processing.
Credit card (Visa and Mastercard*), cheque, postal money order,
bank money order
By mail
At a service counter
Cash, debit card (Interac), credit card (Visa and Mastercard*),
cheque, postal money order, bank money order
You can also submit your application at certain Services Québec
offices that provide Directeur de l’état civil services. See our
website for the list of offices or contact us.
By mail
Directeur de l’état civil
2535, boulevard Laurier
Québec (Québec) G1V 5C6
At a service counter
How to submit the application?
Québec
2535 boulevard Laurier
Ground floor
Montréal
2050 rue De Bleury
Ground floor (RC.01)
Integral reproduction of the information contained in the act, document number
(since March 29, 2005) and date of issue.
Note: This document may show information pertaining to several civil status events.
Surname, given names, sex, place of birth, date and time of birth, registration number, document number (since
March 29, 2005), date of issue and, where applicable, notation entered in the act since it was drawn up.
Surname, given names, sex, date, time and place of birth, registration number, surnames and given names of the
father and the mother, document number (since March 29, 2005), date of issue and, where applicable, notation
entered in the act since it was drawn up.
Type and format Information contained in the document *
Which document to request: the certificate or the copy of an act of birth?
Before applying for a certificate or a copy of an act, inquire about the type and format of the document required by the organization to which it
must be submitted.
For a minor child, we recommend the long−form birth certificate because it states the parents’ names. Certain organizations require that
this document be provided for a person under 18 years of age.
If the format is not indicated in the application, the long−form birth certificate will be issued.
Ministère du Travail, de l’Emploi et de la Solidarité sociale
Information may be missing if the event occurred before 1994.
*
Naissance FO−11−13 (2021−04−01)
Birth certificate
Short−form
8.7 cm x 5.5 cm
Birth certificate
Long−form (recommended)
21.5 cm x 18.5 cm
Copy of an act of birth
21.5 cm x 26.7 cm
2 of 4
Cheques and postal or bank money orders must be made payable to
the Directeur de l’état civil.
* Visa and MasterCard debit cards are not accepted.
Return to form
Only the identity documents listed below are accepted. If you
cannot provide one of these documents, contact us to
determine the solution best suited to your situation or fill out the
Declaration du répondant form and attach it to your application.
This form is available on our website.
Health insurance card issued by a Canadian province and
bearing a photograph
Driver’s licence, learner’s permit or probationary licence issued
by Québec, another Canadian province or territory or a US
state
The driver’s licence, learner’s permit or probationary licence is
accepted as photo ID only if it is not submitted as proof of
home address.
Canadian or foreign passport
Canadian Citizenship Card (issued between 2002 and 2012)
Canadian Permanent Resident Card
US Permanent Resident Card (green card)
Canadian immigration document IMM 1442
Official IDs for members of the military, police officers or
diplomats posted in Canada
Certificate of Indian Status
ID card issued by a Canadian province or territory
Valid photo ID
Driver’s licence, learner’s permit or probationary licence issued
by Québec, another Canadian province or territory or a US
state
The driver’s licence, learner’s permit or probationary licence is
accepted as proof of home address only if it is not
submitted as photo ID.
Municipal or school tax bill (no more than one year old)
Government postal correspondence (no more than one
year old)
Recent bill from an energy, telephone service or cable provider
(no more than three months old)
Construction competency certificate (apprentice or
journeyperson)
Hospital card accompanied by a health insurance card bearing
a photograph
Canada Post change of address receipt (no more than three
months old)
Record of employment or pay slip (no more than three months
old)
Home or car insurance certificate or statement (no more than
one year old)
School transcript (no more than one year old)
Bank statement (no more than three months old)
Only the proofs of home address listed below are accepted. If you
cannot provide one of these documents, please contact us.
Valid proof of home address
All documents submitted must be in effect or comply with the validity
period specified. The document’s validity is determined according to
the date the Directeur de l’état civil receives the application.
Document validity
Remember to include the photocopy of the back of a document
when required, particularly if it shows a change of address or expiry
date.
Front and back document
If the required documents are written in a language other than
French or English, attach a French translation done or certified true
by a member of the Ordre des traducteurs, terminologues et
interprètes agréés du Québec.
Language of documents
Website: www.ottiaq.org
E−mail: info@ottiaq.org
To contact the Ordre des traducteurs, terminologues et
interprètes agréés du Québec
If you are submitting more than one application form at a time,
attach separate photocopies to each form to speed processing.
Separate photocopies
All photocopied documents must be legible.
Quality of photocopies
The Directeur de l’état civil applies security measures to ensure that a person who applies for a civil status document is authorized to obtain it.
To establish the identity of applicants, we require that they attach two documents issued by two separate organizations:
a valid photo ID
a valid proof of home address
If you submit your application by mail, you must attach photocopies, not original documents.
If you submit your application or request a document at a service counter, you must present original documents, not photocopies, to the
clerk.
Digital documents are not accepted as a valid photo ID.
Certain digital documents are accepted as a valid proof of home
address:
What documents are used to establish the applicant’s identity?
Ministère du Travail, de l’Emploi et de la Solidarité sociale
Naissance FO−11−13 (2021−04−01)
3 of 4
Return to form
Directeur de l’état civil
2535, boulevard Laurier
Québec (Québec) G1V 5C6
By mail By email
etatcivil@dec.gouv.qc.ca
Website
www.etatcivil.gouv.qc.ca
By phone
Québec:
Montréal:
Elsewhere in Québec:
Teletypewriter (TTY):
418 644−4545
514 644−4545
1 877 644−4545
1 800 361−9596
Only you, as the applicant, can obtain information on the status of your application. You must
contact us by phone or go to one of our service counters.
To reach us
This section is a reference tool. The "Information" pictogram appears in certain boxes on the form. It indicates that particular
information is provided to help you complete the form correctly.
Use the family name as indicated on the act used to enter the
birth in the register. In cases involving adoption or a name
change, enter the family name used after the adoption or the
name change.
Box 12 − Surname
Complete this box only if the person was born before 1994.
Enter the name of the place of worship or parish and municipality
(city, town or village) where the religious registration took place,
or the name of the municipality in the case of a civil registration.
Box 18 − Place of registration of the birth if it occurred
before 1994 (parish, place of worship, city, town, village or
municipality)
Section 2: Information on the birth of the person concerned
The usual given name is a name that, in addition to being
mentioned in the act, is used on a daily basis to identify the
person and confirm his or her identity.
Box 13 − Usual given name
4 of 4
Instructions
Section 1: Information on the applicant
Boxes 1 and 2 − Applicant’s surname and given name
Enter your surname and given name. This name must match the
family name indicated on the photo ID and proof of home
address submitted.
Boxes 10 and 11 − If the application concerns someone
other than yourself or your child, explain why you are
applying and attach the photocopy of an official document
as proof.
As you are not mentioned in the act of birth in question, you must
establish why you wish to obtain a certificate or a copy of an act
concerning this person and provide a photocopy of an official
document to prove the reason given. Use an extra sheet if you
need more space to state your reason. However, if the document
for which you are applying concerns someone who is deceased
and you are that person´s spouse, child or sibling, you do not
have to provide a photocopy of an official document establishing
your reason. Rather, you must enter your date of birth in Box 10,
if you were born in Québec, or attach a photocopy of a civil
status document proving your family ties to the deceased, if you
were not born in Québec.
Box 3 − Home address (number, street, apartment)
The address must match the address indicated on the proof of
home address submitted. The documents requested will be sent
to this address.
Box 9 − Phone number (other)
Indicate a phone number where we can reach you during the
day or where we can leave a message, if necessary.
Section 4: Applicant’s declaration
Box 32 − Applicant’s signature
The signature of the applicant (the person named in Section 1 of
the form) is mandatory. If the declaration is not signed, your
application will be refused.
Section 5: Methods of payment
Box 35 − Credit card
The cardholder’s signature is mandatory even if he or she also
signed as the applicant. Without the cardholder’s signature in the
appropriate place, the application will be refused.
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Ministère du Travail, de l’Emploi et de la Solidarité sociale
Naissance FO−11−13 (2021−04−01)
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Form 20210401: N . 2021-2022 i BIRTH Application (Qubec)

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Completed 18 May 2021

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