*If adopted, please provide your adoptive name and adoptive parents’ information. VS-39B REV 8/09
*If you had your name legally changed, please provide a copy of the court documents authorizing the name change.
REQUEST FOR A CERTIFIED COPY OF A BIRTH RECORD FROM THE TOWN
Mail this request to the Town Vital Records office. For the address and phone number of Town Vital
Records offices in Connecticut, please refer to our website at www.ct.gov/dph.
PLEASE PRINT
FULL NAME ON CERTIFICATE*:________________________________________________________________________________
FIRST MIDDLE LAST NAME
DATE OF BIRTH: ________/________/________ PLACE OF BIRTH: _____________________________________________
MONTH DAY YEAR TOWN/CITY
FATHER’S FULL NAME: ________________________________________________________________________________________
FIRST MIDDLE LAST NAME
MOTHER’S MAIDEN NAME: ____________________________________________________________________________________
FIRST MIDDLE LAST NAME
PERSON MAKING THIS REQUEST:
NAME: ________________________________________________________________________________________________________
FIRST MIDDLE LAST NAME
ADDRESS: _____________________________________________________________________________________________________
NUMBER/STREET/UNIT #
TOWN/CITY: __________________________________________________ STATE: _____________ ZIP CODE: _____________
TELEPHONE NO: ____________________________________ E-MAIL ADDRESS: ______________________________________
SIGNATURE: X_________________________________________________________________________________________________
RELATION TO PERSON NAMED ON CERTIFICATE: ______________________________________________________________
REASON FOR MAKING REQUEST: ______________________________________________________________________________
CERTIFICATE SIZE:
FULL SIZE WALLET SIZE
TOTAL NUMBER OF COPIES:
$20.00 EACH
NUMBER OF COPIES: __________
The wallet size birth certificate contains less
information than the full size certificate. It
may not satisfy all proof of identification
requirements such as those needed for a
passport.
$15.00 EACH
NUMBER OF COPIES: __________
_______ X $20.00 = $ _______
_______ X $15.00 = $ _______
TOTAL: $ _______
PLEASE DO NOT MAIL CASH.
Attach a copy of the requester’s valid government issued photo
ID or passport below:
Or two (2) forms of the following:
- Social security card
- Written verification of identity from employer
- Automobile registration
- Copy of utility bill showing name and address
- Voter’s registration card
Please make sure to mail the completed request with the
following requirements:
Money order made payable to City/Town (check our
website stated above)
Current government issued photo ID
(If applicable) verification of relationship to the registrant
(for example, an individual requesting his/her parent’s
birth certificate must provide a certified copy of his/her
own birth certificate).
