REQUEST FOR CERTIFIED COPY OF A BIRTH RECORD
NORTH DAKOTA DEPARTMENT OF HEALTH
DIVISION OF VITAL RECORDS
SFN 8140 (07-2019)
PLEASE PRINT - ALL ITEMS MUST BE COMPLETED AND LEGIBLE TO LOCATE AND IDENTIFY THE RECORD
1. Full Name on Birth Record (If adopted, list adoptive name)
2. Sex
Male Female
4. Place of Birth or Death (City, Township or County)
3. Date of Birth or Death (Month, Day, Year)
5. Full Name of Father (First, Middle, Last) (If adopted, list adoptive father/parent name)
6. Full Name of Mother (First, Middle, Maiden) (If adopted, list adoptive mother/parent name)
7. Number of Certified Copies Requested ($15.00 per copy requested)
Certified (For all official purposes, including U.S. Passport, Driver’s License, etc.)
Genealogy (For researching family history - not available for births occurring after 2005)
8. Fees: (Check or Money Order)
$ .00
9. Your Relationship to Person on Line 1*
Self (must be 16 or older) Mother/Father Public (Only if record is over 125 years old) Authorized Rep (include court order)
Legal Guardian (must include guardianship papers - Social Services must also include employment photo ID)
* If individual on line #1 is deceased and you are the
spouse, parent, child, grandparent, or grandchild, you may request birth record.
You must include a certified copy of the death record.
Requestor Signature
Date
Requestor Printed Name
Daytime Telephone Number
( )
Mailing Address Apartment Number
City
State
ZIP Code
Shipping Options: (First Class Mail is the no cost default)
First Class Mail - (Free) FedEx - $16 (Add $6 for AK or HI) UPS - $16 Waive Signature for FedEx or UPS Delivery
IDENTIFICATION REQUIRED - All applicants must submit A) One Primary form of ID; OR B) Two Secondary forms of ID;
OR C) Submit a Notarized application. (Choose A or B or C) - Acceptable forms of identification listed on back of the form)
Date Subscribed and Sworn Before Me
SEAL
Signature of Notary Public
My Commission Expires
Warning - NDCC 23-02.1-32(c) Penalties. Any person who willfully or knowingly uses or attempts to use or to furnish to another for use,
for any purpose of deception, any certificate, record, report, or certified copy thereof so made, altered, amended or mutilated shall be
guilty of a class C felony.
PLEASE DO NOT ENTER ANYTHING BELOW THE LINE - THIS PORTION FOR OFFICIAL VITAL RECORDS OFFICE USE ONLY
Identification Verified Fee Received
SFN 8140 (7-2019)
Page 2 of 2
INSTRUCTIONS FOR OBTAINING A CERTIFIED COPY OF A BIRTH RECORD
The Division of Vital Records can issue copies of birth certificates only for births that occurred in North Dakota. We have
records on file starting with 1870 to the present.
Proof of identification must be submitted before we can issue a certified copy of a birth record. Proof of identification can be
established by having this form NOTARIZED in the space provided on the front, or by submitting a legible photocopy of ONE
of the following PRIMARY forms of identification:
1. State Government issued Photo ID or Driver's License
2. Bureau of Indian Affairs issued tribal ID card
3. US Government issued Military ID card
4. US Government issued Passport or Visa
5. US Government issued Permanent Resident Card
If you cannot provide one of the primary forms of identification listed above, proof of identity can still be established by
submitting a legible photocopy of TWO of the following SECONDARY forms of identification:
1. Social Security Card
2. Medicare/Medicaid Card
3. Utility bill with the current address (within the last three months)
4. Bank Statement with the current address (within the last three months)
5. Pay Stub (within the last three months) or W-2 (issued for the previous tax year)
6. Motor Vehicle Registration Card for the current year with the current address
The fee for a search of the files is $15; one search fee pays for one certified copy. Please make your check or money
order payable to North Dakota Department of Health. We will issue a certified raised-seal paper copy for each copy
requested.
Once received in our office, copies are usually mailed in 3 to 5 business days (this does not include the mailing time).
Copies to be sent by Federal Express or UPS are processed the same day, provided the request is in our office by 10:00
a.m. Central Time.
Certified copies CANNOT be faxed. The certified copies will be sent by first class mail unless you specify and include the
funds for special shipping through Federal Express for an additional $16.00 (add $6 for delivery to Alaska or Hawaii) or
UPS for an additional $16.
This form may be completed and mailed with fees to:
ND Department of Health
Division of Vital Records
600 East Boulevard Ave. Dept. 301
Bismarck, ND 58505-0200
Our web page is at: www.health.nd.gov/vital
For questions, call our office at (701) 328-2360 or e-mail us at vitalrec@nd.gov.