VR206-Evidence for Individuals web.doc DVRA Supervisor Approval Signature: rev 6/2012
State of New Hampshire
Department of State
Division of Vital Records Administration
71 South Fruit Street
Concord, New Hampshire 03301-2410
(603) 271-4650 or (603) 271-4662
DOCUMENTARY EVIDENCE REQUIRED
Effective January 1, 2005, all individuals requesting a certified copy of a record (Pursuant to RSA 5-C:102, VI) must
present positive identification, including, but not limited to, a driver’s license, passport or other government issued picture
identification.
Or:
Those without acceptable photo identification shall supply a photocopy of two (2) documents listed below. Any document
submitted shall be in the name of the individual requesting the record.
(Example: if a utility bill is sent, the name and address of the requestor must be listed.)
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Failure to sign & submit two acceptable documents in place of the required picture identification shall result in
the application being rejected & returned to the requester. One of the documents must
reflect current physical
address. If no document submitted matches your current address, click on this notarization form.
THIS FORM SHALL ACCOMPANY THE APPLICATION REQUIRING A CERTIFIED COPY
OF A NEW HAMPSHIRE VITAL RECORD.
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I declare that I do not have picture identification and that I have presented the TWO ATTACHED documents:
Please PRINT the following information:
Name of applicant
Applicant’s residence address (house number, street name, city/town, state, zip code)
Signature of applicant Date of signature
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____ Social Security Card / DD-214
____ Hospital Birth Worksheet
____ Lease/Rental Agreement
____ Copy of income tax return
____ Personal check with address
____ Voter Registration Card
____ A previously issued vital record/marriage license
____ Disability award from SSA
____ Letter from government agency requesting a vital record, e.g., DHS, WIC
____ Department of Corrections Identification Card
____ Other: ______________________________________________________________________________________
Description
ATTACH photocopies of BOTH documents to this form when returning the application.
