Fillable Requirement for ordering: If applicant is self, parent, (Florida Department of Health)

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Requirement for ordering: If applicant is self, parent, (Florida Department of Health)

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DH 726, 04/2016, Florida Administrative Code Rule 64V-1.0131 (Obsoletes Previous Editions)
State of Florida
Department of Health
Office of Vital Statistics
APPLICATION FOR FLORIDA BIRTH RECORD
Requirement for ordering: If applicant is self, parent, guardian, or legal representative, then the applicant must complete this application and provide a copy of a valid photo
identification. If applicant is not one of the above, the Affidavit to Release a Birth Certificate must be completed by an authorized person and submitted in addition to this
application form. Acceptable forms of identification are the following: Driver’s License, State Identification Card, Passport, and/or Military Identification Card.
SECTION A – REGISTRANT INFORMATION
CHILD’S FULL NAME AS
SHOWN ON BIRTH RECORD
FIRST
MIDDLE
LAST
SUFFIX
IF NAME WAS CHANGED SINCE
BIRTH, INDICATE NEW NAME
FIRST
MIDDLE
LAST
SUFFIX
DATE OF BIRTH
DAY
YEAR (4-DIGIT)
STATE FILE NUMBER (If known)
SEX
PLACE OF BIRTH
HOSPITAL
CITY OR TOWN
COUNTY
MOTHER’S / PARENT’S NAME
FIRST
MIDDLE
LAST NAME PRIOR TO FIRST MARRIAGE (if applicable)
SUFFIX
FATHER’S / PARENT’S NAME
FIRST
MIDDLE
LAST NAME PRIOR TO FIRST MARRIAGE (if applicable)
SUFFIX
SECTION B – FEES & PAYMENT
A BIRTH RECORD SEARCH REQUIRES ADVANCE PAYMENT OF A NON-REFUNDABLE SEARCH FEE OF $9.00 AND VALID PHOTO IDENTIFICATION.
A Computer Certification requires the $9.00 fee which entitles the applicant to one registered birth (1917 to present) or if a
record is not found, a certified “No Record Found” statement will be issued.
The Computer Certification is recognized and accepted by ALL State and Federal Agencies.
Normal processing time is 4-6 days, provided the record and application are complete and in order.
$9.00
X
1
=
$9.00
A Photocopy Certification (in place of a Computer Certification) requires an additional charge of $5.00 and includes the $9.00 search
fee. Normal processing time is approximately 10 business days.
Definitions of the two types of Certifications are on the reverse side.
$5.00
X
1
=
Additional Computer Certifications:
$4.00 for each subsequent Computer Certification
$4.00
X
=
Additional Photocopy Certifications:
$4.00 for each subsequent Photocopy Certification
$4.00
X
=
Additional Years to be Searched:
$2.00 for each additional year. The maximum additional year search fee is $ 50.00 regardless of the total number of years to be
searched. (Indicate the range of years to be searched in the 2
nd
Box.)
$2.00
X
=
RUSH ORDERS (Optional): RUSH Fees are an additional $10.00.
If you desire RUSH service, mark the outside of your envelope “RUSH” (Processing time in our office for Rush Service
is 2-3 business days; routine processing time within our office is 4-6 business days.)
Check here for Rush Order
TOTAL AMOUNT ENCLOSED: Check or Money Order Payable to: Vital Statistics. (DO NOT SEND CASH)
International payments should be made by Cashier’s Check or Money Order in U. S. Dollars.
Florida Law imposes an additional service charge of $15.00 for dishonored checks.
Total Amount Enclosed
SECTION C – APPLICANT/MAILING INFORMATION
Any person who willfully and knowingly provides any false information on a certificate, record or report required by Chapter 382, Florida Statutes, or on any application or affidavit, or who obtains
confidential information from any Vital Record under false or fraudulent purposes, commits a felony of the third degree, punishable as provided in Chapter 775, Florida Statutes.
Applicant’s Name
TYPE OR PRINT
FIRST
MIDDLE
LAST (INCLUDING ANY SUFFIX)
DELIVERY ADDRESS (INCLUDE APT. NO., IF APPLICABLE)
CITY
STATE
ZIP CODE
HOME PHONE NUMBER (with area code first)
WORK PHONE NUMBER (with area code first)
RELATIONSHIP TO REGISTRANT
SIGNATURE OF APPLICANT
IF ATTORNEY, PROVIDE BAR/PROFESSIONAL LICENSE NO.
IF ATTORNEY , PROVIDE NAME OF PERSON YOU REPRESENT AND THEIR RELATIONSHIP TO REGISTRANT
IF THE CERTIFICATION IS TO BE MAILED TO ANOTHER PERSON OR ADDRESS USE THE SPACES BELOW TO SPECIFY SHIP TO NAME AND ADDRESS.
SHIP TO NAME
TYPE OR PRINT
FIRST
MIDDLE
LAST (INCLUDING ANY SUFFIX)
HOME PHONE NUMBER
SHIP TO STREET ADDRESS (AND APT. NO. IF APPLICABLE)
WORK PHONE NUMBER
CITY
STATE
ZIP CODE
Print
Clear Form
DH 726, 04/2016, Florida Administrative Code Rule 64V-1.0131 (Obsoletes Previous Editions)
INFORMATION AND INSTRUCTIONS FOR BIRTH RECORD APPLICATION
COMPUTER CERTIFICATION: The Computer Certifications are accepted by all State and Federal Agencies and used for any type of travel. 4-6 days is
the Normal Response time, provided the record and application are complete and in order.
A Computer Certification has two different formats which are:
A certification of a registered birth (2004 to Present), supplies the following facts of birth: Childs Name, Date of Birth, Sex, Time, Weight, Place of
Birth (City, County and Location) and Parents Information.
A certification of a registered birth (1917 to 2003), supplies the following facts of birth: Childs Name, Date of Birth, Sex, County of Birth and
Parents Name.
If the birth occurred prior to 1917, only photocopies are available. When ordering, select Computer Copy for $9.00. Records are available from 1865
to present but are limited from years 1865-1916.
TIME OF BIRTH: This item was not collected on the birth events between 1949 -1969.
PHOTOCOPY: A photocopy is a certificate of the registered birth on file. Photocopies of birth certificates are certified documents. Normal response time for
photocopies is approximately 10 days.
AVAILABILITY: Birth registration was not required by state law until 1917, but there are some records on file dating back to 1865. Birth records under seal
by reason of adoption, paternity determination or court order cannot be ordered in this manner. For a record under seal, write to ATTN: Records Amendment
Section at the address below.
ELIGIBILITY: Birth certificates can be issued only to:
1. Registrant (the child named on the record) if of legal age (18)
2. Parent(s) listed on the Birth Record
3. Legal Guardian (must provide guardianship papers)
4. Legal representative of one of the above persons
5. Other person(s) by court order (must provide recorded or certified copy of court order)
In the case of a deceased registrant, upon receipt of the death certificate of the decedent, a certification of the birth certificate can be issued to the spouse, child,
grandchild, sibling, if of legal age, or to the legal representative of any of these persons as well as to the parent.
Any person of legal age may be issued a certified copy of a birth record (except for those birth records under seal) for a birth event that occurred over 100 years
ago.
REQUIREMENT FOR ORDERING: If applicant is self, parent, legal guardian or legal representative, then the applicant must provide a completed
application along with a copy of a valid photo identification. If legal guardian, a copy of the appointment orders must be included with your request. If
legal representative, your attorney bar number, and a notation of whom you represent and their relationship to the registrant must be included with your
request. If you are an agent of local, state or federal agency requesting a record, indicate in the space provided for “relationship” the name of the agency.
Acceptable forms of identification are the following: Driver’s License, State Identification Card, Passport and/or Military Identification Card.
RELATIONSHIP TO REGISTRANT: A person ordering his or her own certificate should enter "SELF" in this space. Also, explain if name
has been changed; married name, name changed legally (when and where), etc. Others must identify themselves clearly as eligible (see
ELIGIBILITY above).
FEES ARE NONREFUNDABLE: Fees are nonrefundable, except fees paid for additional copies when no record is found. These are refunded on
written request.
APPLICANT’S SIGNATURE: is required, as well as his/her printed name, residence address and telephone number.
OPTIONS FOR RUSH SERVICE:
CREDIT CARDS: The state office currently does not accept credit cards but there is a private firm that accepts such charges and transfers the order
to Vital Statistics for a fee of $7.00 plus a $10.00 Rush Fee charged by the State Office. You may telephone 1-877-550-7330 or you may fax your
request to the private firm at 1-877-550-7428. In any event, you may dial (904) 359-6900 and follow the prompts on the telephone system to be
transferred free of charge to the contracted vendor. If you have any questions please call the Office of Vital Statistics at (904) 359-6900.
MAIL IN: An order with an envelope marked RUSH with a $10 rush fee enclosed, provided the record and application are complete and in order,
will be processed before the normal processing time. This does not include birth records requiring an amendment action. If an amendment action is
necessary, additional processing time will be required.
WALK-IN SERVICE: Is available at 1217 Pearl Street, Jacksonville, Florida, between 8:00 am – 4:30 pm. Each request must be
accompanied by picture identification. Certifications for photocopies rush service requires an additional fee of $10.
MAIL THIS APPLICATION WITH PAYMENT TO:
DEPARTMENT OF HEALTH
OFFICE OF VITAL STATISTICS
ATTN: VITAL RECORDS SECTION
P.O. BOX 210,
Jacksonville, FL 32231-0042
(Street Address: 1217 North Pearl Street, Jacksonville, Florida, 32202)
PLEASE VISIT OUR WEBSITE:
www.FloridaVitalStatisticsOnline.com
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Completed 20 July 2020

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