REQUEST FOR CERTIFIED COPY OF BIRTH CERTIFICATE
1. Full name at birth :
2. Date of Birth : 3. Place of birth :
4. Father’s full name : Birthplace :
(State only)
5. Mother’s maiden name : Birthplace :
(State only)
This application is for : __ myself __ my child __my spouse*
__ my parent* __minor grandchild*
*Must provide documentation of relationship for spouse, parent, grandchild
*birth certificate [my parent, my grandchild] or marriage certificate [spouse]
Type of copy desired : ___Wallet Size $15.00 ___ Full Size $ 20.00
(Applicant must be 16 years or older) (Applicant must be 18 years or older)
__ Protective cover ($1.00 ea) ___ Birth Envelope ($1.00 ea)
(wallet only) (Full Size Only)
Applicant’s Name : Date :
Applicant’s Signature : Phone: ______________________
Address:
MAIL IN REQUEST:
Must attach a clear copy of a Gov’t issued Photo I. D.
Must include a Self Addressed Stamped Envelope
Must include a money order or certified check (Payable to: Meriden City Clerk)
*Must provide documentation of relationship for spouse, parent, grandchild
*birth certificate [my parent, my grandchild] or marriage certificate [spouse]
Address : Meriden City Clerk Telephone : 203 – 630 – 4030
142 East Main Street
Meriden, CT 06450
*Should a Photo ID be unavailable, Photocopies of TWO of the following are required:
~ Social Security card ~ automobile registration
~ Written verification from employer ~ checking account
~ Copy of utility bill ~ deposit slip
showing name & address ~ voter registration card
CITY/TOWN CLERK USE ONLY
Received by personal request ___
Received by mail request ___
ID Accepted
DATE : / /
FEE : $
Rev. 6/2017 web/mail
Wallet size birth certificate
contains less information than
the full size certificate. It does
not satisfy the proof of
identification requirements
needed for a passport or a
driver’s license.
click to sign
signature
click to edit
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