Statement to Identify
Certified Birth or Death Certificate Applicant
Minnesota Rules, part 4601.2600, subpart 6, require completion of this statement by a witness that has known the applicant for at
least two years.
Witness Information (Please Print)
First Name Middle Name or Initial Last Name
Street Address
City State Zip code
Ten Digit Phone Number Date of Birth Relationship to Applicant
Applicant Information (Please Print)
First Name Middle Name or Initial Last Name Date of Birth
Name on the Birth/Death Record Requested (Please Print)
First Name Middle Name Last Name Date of Birth/Death
I have known the applicant named under Applicant Information for ______ years and solemnly swear or affirm that
he/she is the person presenting the application for a certified birth/death certificate for the person named under Name
on the Birth/Death Record Requested.
Sign in the presence of a registrar or notary and present government issued photo identification. If the
witness cannot accompany the applicant to the registrar's office or if applying by mail or fax, the signature of
the witness must be notarized.
PENALTIES: Any person who willfully and knowingly provides false information for a certified vital record
may be sentenced up to 1 year in jail or a fine of up to $3000 or both. (Minnesota Statutes section 144.227 and
section 609.02, subdivision 3 and 4).
Witness Si
g
nature: Date:
Subscribed and sworn to before me this_______day
of
_____________________________, 20________
__________________________________________ (Seal)
My Commission Expires
______________________
MDH 07/2007
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