Fillable MN Application for a Birth Certificate after Adoption (Minnesota Department of Revenue)

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MN Application for a Birth Certificate after Adoption (Minnesota Department of Revenue)

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The MN Application for a Birth Certificate after Adoption (Minnesota Department of Revenue) form is 2 pages long and contains:

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  • 10 check-boxes
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File type: PDF

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PAGE 1 OF 2 OFFICE OF VITAL RECORDS 07/2021
Application for a Birth Certificate after Adoption
Fill in this form to buy a Minnesota birth certificate that shows the adopted person's
new information.
Minnesota Statutes, section 144.225, subdivision 7, and Minnesota Rules, part 4601.2600 require the information requested on this application.
Birth record information AFTER ADOPTION
Adopted person
(child)
First name after adoption Middle name after adoption Last name after adoption Name suffix
Date of birth (mm/dd/yyyy)
Sex
☐ Female
☐ Male
City of birth County of birth State of birth
MN
Adoptive
Parents
Parent 1 first name Parent 1 middle name Parent 1 last name Parent 1 last name before 1
st
marriage Suffix
Parent 2 first name Parent 2 middle name Parent 2 last name Parent 2 last name before 1
st
marriage Suffix
Requester information
Requester
Requester name Date of birth (mm/dd/yyyy)
Mailing address - Street (UPS® will not deliver to PO boxes or APO addresses) Apt/Unit # Email address
City State
ZIP Code™
Phone number (10-digit )
Requester - You must check ONE box below Requester - Provide documentation indicated
1. ☐ Parent of subject
No documentation required
2. ☐ Subject of the record (adopted person)
No documentation required
3. ☐ Governmental agency – local, state, tribal or federal
Photocopy of employee ID
4. ☐
Attorney representing the subject of the record or
another person listed in Minnesota Statutes, section 144.225,
paragraph(a), clause (1).
MN Attorney License Number: ____________________
NON-MN Attorney - Attach photocopy of license
Signature and Notary (Sign this form in front of a notary if you mail or fax your application)
I certify that the information provided on this application is accurate and complete to the best of my knowledge.
Requester’s signature Notary stamp/seal
Signed or attested before me on __________ day of _________________, 20____
Printed name of notary
Notary public signature My commission expires
It is against the law to provide false information to obtain a certified vital record. You may be subject to fines, jail time
or both. Minnesota Statutes, section 144.227 and section 609.02, subdivisions 3 and 4.
PAGE 2 OF 2 OFFICE OF VITAL RECORDS 07/2021
Application for a Birth Certificate after Adoption
Requester name
Replacement birth record Fee Replacement
Register replacement birth record $40 $40
How many certified birth certificates do you want? Fee Certificates
One certified birth certificate $26
Additional birth certificates purchased at the same time cost $19 each.
# of extra copies
X $19
each
How do you want us to process your request? Fee Processing
Standard – your request is processed in the order it was received $0
Faster – your request goes ahead of Standard requests (The $20 does not include UPS® delivery) $20
How do you want us to deliver your order? Fee Delivery
Regular First Class Mail ® $0
United Parcel Service (UPS®) $16
For UPS® delivery, check here ☐ to require a signature. The Office of Vital Records and UPS® are not responsible for deliveries
that do not require a signature. UPS® will not deliver to PO boxes or APO addresses. If you want UPS® delivery to an address
outside of the United States, you must include a UPS® prepaid envelope when you submit your application and fees.
The amount you pay must cover the certificates and services you requested Amount due
Amount due = Replacement + Certificates + Processing + Delivery
How do you want to pay?
☐ Credit card
MasterCard/Visa/Discover
Cardholder name Valid thru MM/YY
Card number 3-digit security code
☐ Check
Check number
Make your check or money order payable to the
Minnesota Department of Health. Send it by mail with
your application. DO NOT SEND CASH.
☐ Money
order
Money order number
Checks returned for non-payment will result in a $30
charge to you. You could also face civil penalties.
Minnesota Statutes, section 604.113, subdivision 2.
Send your application and check, money order, or credit card information
By mail (Do not send cash)
Minnesota Department of Health
Office of Vital Records
PO Box 64499
St. Paul MN 55164-0499
By fax 866-416-1357
Application with credit card information only
The O
ffice of Vital Records returns applications that are:
▪ Incomplete
▪ Not signed in front of a notary public
▪ Not paid in full at the time of application
If you have questions, please contact health.vitalrecords@state.mn.us or call 651-201-5970.
To obtain this information in a different format, call 651-201-5970.
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MN Application for a Birth Certificate after Adoption (Minnesota Department of Revenue)

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Completed 4 May 2022

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