Fillable Request A Birth Certificate (City of Providence)

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Request A Birth Certificate (City of Providence)

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The Request A Birth Certificate (City of Providence) form is 1 page long and contains:

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Please Print Clearly
Providence City Registrar, Providence City Hall, Room 104
25 Dorrance St., Providence, RI 02903
Application for a Certified Copy of a Birth Record
Please complete ALL items 1
-
5 below:
1. Fill in the information below for the person
Full name at birth _______________________________________________________
Age now_________________
New name if changed in court (excluding marriage)______________________________________________________
Da
te of birth
City/town of birth___________________ Hospital
Mother’s/parent's full at birth______________________________________________________________________
Father’s/parent's full at birth________________________________________________________________________
2. I am applying for the birth record of (complete
one
of the following):
myself
my child
my mother/father
my grandchild (parent of mother)
my grandchild (parent of father
)
my brother/sister
my client
--
I’m a social worker. Name of my agency is_______________________________________
my client
--
I’m an attorney representing:_____________________________________________
_______
The name of the law firm is:
.
another person (specify your relationship):__________________________________________________
3.
Why do you need thi
s record? (We ask this question so that we can supply you with a certified copy that will be
suitable for your needs.)
school
license
vets benefits
social security
passport/travel
foreign govt
4.
work WIC welfare other use (specify)______________________
Walk-in copies cost $22.00. Mail-in copies cost $25.00.
Any additional copies of this record purchased this same day cost $18.00 each
How many do you want? _______
et
-
5.
I hereby state that the information supplied in item #2 above is true and that I am not in violation of Section
23
-
3
-
28 of the General Laws of RI (printed on the reverse side of this form).
Please s
ign_____________________________________________________________ ______________________
Signature of person completing this form
date signed
Print your name_______________________________________________
(
)____________________
_______
phone #
Print your address_______________________________________________________________________________
street or mailing address
city/town
state
zip code
************************BELOW THIS LINE FOR OFFICE USE O
NLY**************************
Type of picture ID:____________________ID number: _____________ID issued by:_____________
VS
-
82B (Rev. 08/07)
************************BELOW THIS LINE FOR OFFICE USE ONLY**************************
State/Local File # ________
__ Amt. rec’d _________ Rec’t #
Date sent ________ Initials______
Birth
Death
Marriage
Number of first copies
_________ _________ _________
Number of additional copies _________ _________ _________
Number of searches
__
_______
Additional years searched
_________
FOR STATE USE ONLY:
Delayed filing
Correction
P/L
A
Section 23
-
3
-
28 of the General Laws
I understand that Section 23
-
3
-
28 of the General Laws of Rhode Island provides penalties for either
of the
following violations:
Any person who willfully and knowingly makes any false statement in a report, record, certificate or application
for an amendment thereof, or who willfully and knowingly supplies false information intending that such
informati
on be used in the preparation of any of the such report, record, or certificate, or amendment thereof . . .
. . shall be punished (if convicted) by a fine of not more than one thousand dollars ($1,000) or imprisoned not
more than one (1) year or both.
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Request A Birth Certificate (City of Providence)

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Completed 14 July 2020

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