REQUEST FOR A CERTIFIED COPY OF A BIRTH OR DEATH CERTIFICATE
Choose one (1) primary document or two (2) alternate documents that you are providing with this request.
U.S. issued Driver’s License or
U.S. Territories Driver’s License or
Tribal ID Card containing your signature
U.S. Military ID Card containing your signature
Passport: U.S. or Foreign issued
VISA: U.S. issued and included within a Passport
containing your signature
U.S. Resident Alien Card or U.S. Green Card or
U.S. Permanent Resident Card (Form I-551)
U.S. Employment Authorization Document or
Card (Form I-765)
Document # ___________________________
Expiration Date: __ ___ /__ /__ __ __ __
These two documents together must contain your
current address and your signature.
Employment Photo ID Card with a Pay Stub or
U.S. Internal Revenue W-2 form
School, University or College Photo ID with
Report Card or other proof of current enrollment
Department of Corrections ID Card with
probation documents or discharge papers
Social Security or Medicare Card with your
Car Registration or Title with current address
U.S. Selective Service Card
Voter’s Registration Card
Filed Federal Tax Form with
Bank Statement or Utility Bill (gas, water,
electric, sewer, phone) with current address
U.S. or State Court documents with current
Total Number of Copies Requested: ______
Make checks or money orders (U.S. funds) payable to : Brattleboro Town Clerk. Mail
this form and a self-addressed envelope, or bring the form with payment to: 230 Main St, Ste 108
Brattleboro VT 05301.
FOR OFFICE USE ONLY:
ID checked and validated by:
Fee enclosed: $
Any person who knowingly makes a false statement, misrepresentation or certification as to any material
fact on this application shall be fined not more than $10,000 or imprisoned for not more than six months or
both. 18 V.S.A. § 131(c).
I certify that the information provided on this form is true and I am eligible to receive a certified copy.
Signature*: Date Signed*: ______________
To pay by credit card call 802-251-8157. The form will need to be
scanned then emailed or faxed to our office for this payment option.