Fillable Iowavitalrecordjuly2019 APPLICATION FOR AN IOWA VITAL RECORD

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Iowavitalrecordjuly2019 APPLICATION FOR AN IOWA VITAL RECORD

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U.S.A. forms for Polk County

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Iowa Department of Public Health, Bureau of Health Statistics UPDATED July 1, 2019
Do not use any unapproved third party vendor to obtain this form. Do not pay a fee for this form.
This form is available to print at no cost at https://idph.iowa.gov/health-statistics
Information about requesting a certified copy of an IOWA Birth, Death or Marriage Record
What records are available?
In Iowa, vital record registration began July 1, 1880. Event must have occurred in IOWA. Records older than July 1, 1880 are not on file.
Where are records held?
Original vital records that were registered are on file with the Iowa Department of Public Health, Bureau of Health Statistics. Vital records are
also available for request at local county registrar offices in Iowa.
What records are open for public inspection?
The state vital record system is closed to public inspection. However, birth, marriage and death records may be inspected as of right under
Iowa Code section 22 when in the custody of the county registrar. IAC 144.43
The following is required when applying for a certified copy of an Iowa vital record:
1) Completed application that is legible and clearly identifies the event record and establishes entitlement to the record requested.
2) Applicant’s current government issued photo identification (copy if sent by mail).
3) Payment in the amount of $15 for EACH certified copy requested. Fees payable in U.S. funds by check or money order. Cash
accepted in person ONLY.
4) SIGNATURE MUST BE NOTARIZED ON THE APPLICATION WHEN SUBMITTING VIA MAIL.
Who is entitled to the record?
Entitled persons include the person named on the record or that person’s spouse, children, legal parents, grandparents, grandchildren,
siblings, or legal representative or guardian. Legal guardians, legal representatives, and siblings must also provide additional proof of
entitlement.
What is the fee?
The fee for a certified copy of a vital record in Iowa is $15 each. Fees are payable in U.S. funds by check or money order to the issuing
registrar’s office. Fees must be paid at the time of the application.
What is the process to exchange the small wallet-sized birth cards?
Any pink/blue wallet sized birth certificates issued between 1993 and 2009 can be exchanged for no fee. Follow all instructions above for
applying for a vital record in Iowa. The original pink/blue wallet birth certificate may be returned along with a completed application and proof
of ID (current government issued photo identification) to any issuing office in Iowa. If the wallet-sized birth certificate is not exchanged,
applications must be sent to the state office at the address listed below.
What if the order is not received in the mail?
If the requested documents are not received within 30 days, contact the issuing office. Requested documents cannot be replaced at no fee after 90
days of issuance.
WAYS TO ORDER FROM THE IOWA DEPARTMENT OF PUBLIC HEALTH OR COUNTY RECORDER
Telephone: Customers may call VitalChek toll-free at 1-866-809-0290 from 6:00 am CST through 7:00 pm CST, Monday through Friday,
except for holidays. An additional processing fee will apply. Customers may call the bureau directly at 515-281-4944 to speak to state staff.
In-person: Applications may be made in-person at the Bureau of Health Statistics, 321 E. 12
th
Street, Des Moines, Iowa, from 7:00 a.m. to
4:45 p.m., Monday through Friday, except for state-observed holidays. All application requirements noted above will apply. Applications may
also be made in person at the county recorder offices. Visit
https://idph.iowa.gov/health-statistics for a full list of records held at county
recorder offices.
Postal service: Written requests and fees may be mailed to the address below. All application requirements noted above will apply.
Genealogy requests may take up to 60 business days for processing, regardless of the method of application, and will be mailed to applicants.
Commemorative Certificates – Information regarding commemorative certificates is available at idph.iowa.gov/health-statistics
.
Iowa Department of Public Health
Bureau of Health Statistics
Lucas State Office Building
1
st
Floor, 321 E. 12
th
Street
Des Moines, Iowa 50319-0075
SEE OTHER SIDE FOR AN APPLICATION FORM.
FORM MAY BE USED FOR APPLICATION AT THE BUREAU OF HEALTH STATISTICS OR COUNTY RECORDER OFFICES.
APPLICATION FOR AN
IOWA VITAL RECORD
• Submit all the following:
Completed application for an IOWA birth, death or marriage record;
$15 fee payable in U.S. funds;
Copy of current government issued photo ID;
SIGNATURE MUST BE NOTARIZED WHEN MAILING THE REQUEST.
DID THE EVENT OCCUR IN IOWA? If yes, continue.
If no, you must apply in the state the event occurred.
1. EVENT TYPE (Check one)
BIRTH DEATH MARRIAGE FETAL DEATH
2.
PERSON’S NAME AS IT APPEARS ON THE RECORD
FIRST
MIDDLE, if any
LAST (Surname)
2a. If for Marriage record, SPOUSE’S NAME
FIRST
MIDDLE, if any
LAST (Surname)
3.
DATE OF EVENT (Birth, Death, or Marriage) – BE SPECIFIC – Month, Day, Year
4.
(City and/or County)
5.
PARENT’S FULL NAME PRIOR TO ANY MARRIAGE – First, Middle, Last (Surname)
6.
2
ND
PARENT’S FULL NAME – First, Middle, Last (Surname)
7.
(Birth Only) WAS THE MOTHER MARRIED AT THE TIME OF CONCEPTION OR BIRTH?
Yes
No
Unknown
8. LEGAL ACTIONS TO BIRTH RECORD
None Adoption Paternity Establishment Legal Change of Name
8a. IF A LEGAL ACTION OCCURRED, LIST PREVIOUS NAME (on birth certificate)
Marriage does NOT change the birth certificate.
9.
PURPOSE FOR COPY
10. BIRTHDATE OF APPLICANT
11.
RELATIONSHIP OF PERSON RECEIVING THIS COPY TO PERSON NAMED ON THE RECORD
12.
NAME AND ADDRESS OF PERSON TO RECEIVE THIS COPY: (MUST BE AGE 18 OR OLDER & ENTITLED TO THE RECORD)
12a. Name of Applicant/Recipient
12b. Street address and P.O. Box (if any)
12c. City, State and Zip Code
13. THE CERTIFICATE IS TO BE (Check one)
Mailed Picked up (for in-person requests only)
14.
THE FEE IS $15.00 and one certified copy is issued.
Each additional copy of the same record is $15.00. Indicate the number of copies of this record you need.
15.
THIS REQUEST PAID BY
(Check one)
Check Money Order Cash No Fee Exchange
16. AMOUNT
ENCLOSED
17.
APPLICANT’S NAME (Print clearly)
18. DAYTIME PHONE #
(Include area code)
I certify that the information provided on this application is accurate and complete to the best of my knowledge and that I have legal
entitlement to a certified copy of this record. I have signed below in front of a notary public or an Iowa registrar of vital records.
19.
APPLICANT’S SIGNATURE
20. DATE
APPLICANT’S NAME AS IT APPEARS ON PHOTO I.D. (Print clearly) ___________________________________________________________
(SEAL)
State of _________________ County of ___________________ ss
Signed and affirmed in my presence on this ____ day of ____________ , ________ .
_________________________________ , My commission expires: _____________
Notary Public Signature
Administrative
Use Only
I.D. __________
Initials ________
OFFICE USE ONLY
Application ID ________________________
Security # ____________________________
_____________________________________
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Iowavitalrecordjuly2019 APPLICATION FOR AN IOWA VITAL RECORD

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Completed 28 June 2020

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