Fillable Person requesting to receive a birth certificate must (Summit County Government)

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Person requesting to receive a birth certificate must (Summit County Government)

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COLORADO BIRTH CERTIFICATE REQUEST
Colorado has birth records for the entire state since 1910. Birth certificates are also available from the county office(s); for all county locations visit
http://www.colorado.gov/cdphe
Ways to Order:
In Person: Same day service. Hours are Monday-Friday 8:30 a.m.– 4:30p.m.
Mail Orders: Send check or money order payable to Vital Records to the address
listed on the right. Orders are mailed in 2 weeks after receipt of your request.
Phone Orders: 1-866-300-8540
Online Orders: www.vitalchek.com
Phone and Online orders are mailed 3-5
days after receipt of the request.
Vital Records - Certification
4300 Cherry Creek Drive South
Denver, CO 80246-1530
www.colorado.gov/cdphe
Email: vital.records@state.co.us
Phone: (303) 692-2200
REQUIREMENTS
This request must be completed in full. Please type or print clearly.
Enclose a copy of a current driver’s license, passport or State identification (see reverse side).
Enclose appropriate fees
Person requesting to receive a birth certificate must sign below.
Proof of Relationship is required (Parents and Registrant excluded)
Enclose a copy of the death certificate if the person is deceased.
Requestor Information (Please Print)
Name of Person Making
Request
First Name
Middle
Last
Mailing Address
Street
Apt #
City
State
Zip
Daytime Phone
( )
Physical Address
Street
Apt#
City
State
Zip
( )
Relationship to Registrant*
(person named on
certificate)
*see reverse side
Self Parent Grandparent Step-parent Sibling Spouse Child Stepchild Legal guardian
Legal representative Other_______________________
Reason for Request: Newborn Travel/Passport Records School Insurance Other:___________________
Registrant Information (Please Print)
Person listed on the birth certificate. **If adopted, provide adoptive information and see special service on the bottom of the
reverse
side.**
Full Name at Birth
First
Middle
Last
Date of Birth
Month
Day
Year
__ __ __ __
Is this person deceased? Yes No
If yes, you must provide a copy of the death certificate
Place of Birth
City
County
State
Colorado ONLY
Full Name of Mother
or Parent A
First
Middle
LAST NAME PRIOR TO FIRST MARRIAGE
Full Name of Father or
Parent B
First
Middle
LAST NAME PRIOR TO FIRST MARRIAGE
Pursuant to Colorado Revised Statutes, 1982, 25-2-118 and as defined by Colorado Board of Health Rules and Regulations, applicant must have a direct and
tangible interest in the record requested. The penalties for obtaining a record under false pretenses include a fine of not more than $1,000.00, or impris-
onment in the county jail for not more than one year or both such fine and imprisonment (CRS 25-2-118).
By signing below, I have read and understand that there are penalties for obtaining a record under false pretenses.
Today’s Date
Charges: (FEES NON-REFUNDABLE)
$20.00 for one (or search when no record found) ...................
$13.00 for each additional certificate of the same record
ordered at the same time ................................................
$35 for each heirloom certificate .......................................
$10.00 credit card convenience charge (walk- ins excluded) ......
Please check your shipping method:
Regular Mail ($0.00)
FedEx* next business afternoon (check, money order, cash
ONLY) ($20.00).............................................................
UPS* next business afternoon (credit card orders ONLY)
($20.00) .....................................................................
Total Charges ...............................................................
*Within the continental U.S.
$________
$________
$________
$________
$________
$________
$_______
Credit Card Orders**
Card Type: Visa MasterCard Discover American Express
Cardholder Name:_________________________________________
Card
Number:|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Expiration Date: __________/__________
**$10.00 convenience charge will be added
Sign Here
Clear Form
Proof of Relationship
If your name is not listed on the birth certificate, proof of relationship is required before the birth certificate will be issued (e.g. marriage
certificate, birth certificate, court orders). Certified Birth certificates may be issued to:
• The registrant (person named on the certificate)
• Spouse
• Parents
• Siblings
• Adult children
• Grandparents
• Great grandparents
• Grandchild
• Stepparents
• Legal guardian
Legal representatives of any of the above must present proof of client relationship
For a complete list visit: http://www.colorado.gov/cdphe/vitalrecords
Proof of Identity
◄ ACCEPTED ID DOCUMENTS ►
PRIMARY LIST
Submit one of the following.
No expired documents accepted.
OR
SECONDARY LIST
Submit two of the following ONLY if you do not have
a document listed under the Primary List.
Documents expired more than six months will not
be accepted.
WE CANNOT ACCEPT THE
FOLLOWING:
Alien Registration Receipt/Permanent Resident Card
Certificate of U.S. Citizenship
Jail Temporary Inmate ID: Denver and Pueblo
county
Colorado Department of Corrections ID card
CO Temporary Driver’s license / State ID (must be
current)
Department of Human Services Youth Corrections ID
Employment Authorization Card (I-766)
Foreign Passport
Government Work ID
Job Corps ID
Photo Driver’s license / Photo ID Card (DMV U.S.
only)
School, University or College ID Card (must be
current)
Temporary Resident Card
U.S. B1/B2 Visa card with I-94
U.S. Certificate of Naturalization
U.S. Citizenship ID Card (I-197)
U.S. Military ID card
U.S. Passport
U.S. Merchant Mariner ID / Book
Acknowledgment of Paternity document(Colorado only)
Birth Certificate of Applicant (U.S.A only)
Court order of adoption or name change
Colorado craft or trade license
DD-214
Divorce Decree (U.S.A only)
Hospital birth worksheet (for infants under 6 months)
Hunting or Fishing License (must be current-Colorado
only)
IRS-TIN card
Marriage license (U.S.A only)
Medicare Card
Foreign or International Driving License (with photo)
Mexican voter registration card
Motor vehicle registration or title (U.S.A only)
Pilot license
Selective Service Card (U.S.A only)
Social Security Card
State or federal prison or corrections card
Weapon or gun permit (U.S.A only)
Work ID, Paycheck Stub (within 3 months) or W-2 (Last
tax year)
Any Expired document from the Primary List (cannot be
expired more than 6 months)
Matricula Consular Card
Novelty ID Card
Non-expiring Identification Cards
(unless issued in last 5 years)
Souvenir birth certificates
Out-of-StateTemporary Driver’s
license or Temporary State ID
Medicaid card / WIC
If you cannot provide acceptable identification, it is suggested that you ask a spouse, parent, grandparent, sibling, or adult child, who
can provide appropriate identification, to request the certificate.
**OPTION AVAILABLE FOR ADOPTIONS**
Only an adoptive parent or adopted person is eligible for this special service. ONLY sign below if you wish the statement
“ISSUED PURSUANT TO ADOPTION” to appear on the birth certificate which indicates this person is adopted.
Number of copies to be issued with “Issued pursuant to
adoption” requested: _____
Signature of: adopted person adoptive parent
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Person requesting to receive a birth certificate must (Summit County Government)

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Completed 14 February 2021

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