STACEY KEMP, COUNTY CLERK
APPLICATION FOR CERTIFIED COPY OF BIRTH OR DEATH CERTIFICATE
2300 Bloomdale Road, Suite 2106
McKinney, TX 75071
questions:ctyclerks@collincountytx.gov
972.548.4185
BIRTH - $23.00 Each
NUMBER REQUESTED _____
900 East Park Boulevard, Suite 140C
Plano, TX 75074
questions:ctyclerks@collincountytx.gov
972.881.3025/3029
DEATH - NUMBER REQUESTED
____$21.00 1
st
Certified Copy
____$ 4.00 each additional copy ordered at this time
Full name on record: ______________________________________________________________________________
First Middle Last
Date of Birth or Death_____________________________ County of Birth or Death_____________________________
Father/Parent 1: ___________________________________________________________________________________
First Middle Last
Mother/Parent 2: ___________________________________________________________________________________
First Middle Last (Maiden)
Applicant’s Name: __________________________________________________________________________________
Daytime Phone Number: ____________________________ Email Address: _________________________________
Applicant’s Mailing Address: _________________________________________________________________________
Street City State Zip
Relationship to person named on certificate: _____________________________________________________________
Purpose for obtaining copy of certificate: Please check all that apply.
____Driver License ____Housing ____Insurance ____Passport ____Records
____School ____Social Security ____Travel ____Veterans ____Welfare
Other, please specify: ______________________________________________________________________________
NOTICE: Providing false information on this application is a violation of the law and may lead to fine or imprisonment, or both. The
person to whom any certified copy of Birth or Death Record is issued must be a properly qualified applicant. The applicant must have a
direct and tangible interest in the record and further, should have a significant legal relationship to the person whose record is
requested. The purpose for which the certified copy is needed and the relationship of the applicant to the registrant is essential to
determination as to whether or not the person making the request is a properly qualified applicant. (Health and Safety Code, Chapter
678, Sec. 196.003)
____________________________________________ ________________________________
Signature of Applicant Date
ID#___________________________________ D/O/B________________ Expiration_________________
(Driver’s license, Passport, ID, Etc.)
OFFICE USE ONLY
Volume________ Page________ Check________ Cash________
Austin File No.________________ Security Paper_____________ Money Order_______ Debit/Credit Card ________
