Fillable Form 23: Application for Certified Copy of Vermont

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Form 23: Application for Certified Copy of Vermont

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Application for Certified Copy of Vermont Birth or Death Certificate
23
0 Main St, Suite, 108 Certified Copy Uncertified Copy (informational use only, not for legal purposes)
Brattleboro VT 05301 Fee: $10.00 Fee: $2.00 (fill in this page only – no need to turn over)
Tel: 802-251-8157
Use this form to request a certified birth certificate or death certificate for one person.
Multiple copies of the same certificate can be requested with this form.
Birth Certificate (BC)
Name of Child: First ______________________ Middle ____________ Last* ___________________ Suffix __
Date of Birth*: __ _ /__ /__ __ __ __ Sex*:
Male
Female Town of Birth*: _____________
Name of Mother/Parent: First ______________ Middle ____________ Last _________________________
Name of Father/Parent: First _________________ Middle _____________ Last _________________________
Is this a Certificate of Live Birth for a Foreign-Born Child?
Yes
No
Death Certificate (DC)
Name of Deceased: First ______________________ Middle ____________ Last* __________________ Suffix __
Date of Death*: __ __ /__ /__ __ __ __ Sex*:
Male
Female Town of Death*: ____________
Name of Mother/Parent: First ______________ Middle _____________ Last ________________________
Name of Father/Parent: First _________________ Middle _____________ Last ________________________
Applicant Information
Relationship to Person Named on Certificate*
Self (BC only)
Authorized by Court Order (must present
Spouse document)
Child
Authority for Final Disposition (DC only)
Parent
Social Security Administration (DC only)
Sibling
U.S. Department of Veterans Affairs (DC only)
Grandparent
Deceased’s Insurance Carrier (DC only)
Legal Guardian
Court Appointed Executor or Administrator
Petitioner for Decedent’s Estate (DC only)
Legal Representative (for one of the above)
* = Required Field CONTINUE ON BACK (TURN OVER) July 1, 2019
Your Name: First*____________________________ Middle______________Last*_________________________
If funeral home employee, add business name:___________________________________________________
Mailing Address*:
_____________________________________________ City*:
State: ____________________ Zip code: __ __ __ __ __ Email Address: _________________________________________
Daytime Phone*: (__ __ __) Date of Birth*: __ __/ __ __/ __ __ __ __
________
REQUEST FOR A CERTIFIED COPY OF A BIRTH OR DEATH CERTIFICATE
Identification Document(s)*:
Choose one (1) primary document or two (2) alternate documents that you are providing with this request.
Primary Document
U.S. issued Driver’s License or
ID Card
U.S. Territories Driver’s License or
ID Card
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: __ ___ /__ /__ __ __ __
Alternate Documents
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
signature
Pilot’s License
Car Registration or Title with current address
U.S. Selective Service Card
Voter’s Registration Card
Filed Federal Tax Form with
current
address and
signature
Bank Statement or Utility Bill (gas, water,
electric, sewer, phone) with current address
U.S. or State Court documents with current
Order Summary
Total Number of Copies Requested: ______
x
$10.00 each
=
Order Total:
$ _________________
Make checks or money orders (U.S. funds) payable to : Brattleboro Town Clerk. Mail
your
payment with
this form and a self-addressed envelope, or bring the form with payment to: 230 Main St, Ste 108
Brattleboro VT 05301.
Verification
Date:
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*: ______________
Print Name*:
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.
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Form 23: Application for Certified Copy of Vermont

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Completed 3 November 2020

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