U.S. Department of State 
Request for Birth Certificate form 
Bureau of Consular Affairs 
 
 
 
              Passport services:  Bureau of Consular Affairs 
                                  U.S. Department of State 
                                  Washington, D.C.  20524 
 
 
The Federal government does not maintain copies of birth records of 
persons born in the United States or its Territories.  The State or 
Territory where the birth occurred maintains the record.  See "Office of 
Vital Statistics Addresses" for each State and Territory and the fees 
for certified copies of birth certificates.  THE LISTED FEES ARE SUBJECT 
TO CHANGE.  For your convenience we have included telephone numbers for 
each office.  You should contact the appropriate office for current fee 
information. Also, county or city birth registrars often can provide 
birth certificates.  You may use the form below to request your birth 
certificate.  DO NOT MAIL TO PASSPORT SERVICES.  Please note that some 
States, prior to release, may require the signiture of the subject of 
the birth record or the parent or guardian if the subject is under 18 
years of age. 
 
                   PLEASE DETACH ALONG THIS LINE 
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PLEASE PRINT OR TYPE 
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TO: (Office of Vital Statistics Addresses)




FROM: (Current name and address) 
 
 
 
 
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I request a certified copy of my birth certificate 
to establish birth in the United States.    
 
         _______________________________________________ 
                      (Signature) 
 
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1.  THE NAME UNDER WHICH I WAS BORN IS 
 
 
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2. PLACE OF BIRTH (City, town, county, and state) 
 
 
3. NAME OF HOSPITAL 
 
 
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4. DATE OF BIRTH            5. SEX           6. RACE 
 
 
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7. NAME OF FATHER             8. NAME OF MOTHER (Include maiden name) 
 
 
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9. ENCLOSED (Do not send cash) 
 
Certified check for $____________  Money forder for $____________ 
 
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10. REMARKS 
 
 
11. RETURN THIS FORM WITH BIRTH CERTIFICATE TO:



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