Vital Records Request Form

VITAL RECORDS REQUEST FORM

WHEREAS

WHEREAS the Office of Vital Records maintains permanent civil records of births, deaths, marriages and divorces for the purpose of establishing legal identity, lineage, and for other statutorily permissible uses; and

WHEREAS the requester seeks certified or informational copies of a specified vital record and attests to the truthfulness of the information provided herein and to eligibility to receive the requested record under applicable law;

Applicant Information

Record Requested

Select record type: Birth Death Marriage Divorce Other

Certified copy (suitable for legal use) Informational copy (not certified)

Scope of Request / Purpose

State the lawful purpose for which the record is requested. Misuse of vital records or falsification of purpose may subject the requester to civil or criminal penalties.

Identification & Authorization

Provide a government-issued photo identification. Indicate type and number below and attach a photocopy with this request. Requests without proper identification may be denied.

Driver's License Passport State ID Other

I authorize release of the requested record to: ID for authorized third party (if applicable):

Payment Terms

Fees are required at the time of submission. Fees are non-refundable except where mandated by law. Payment must be made in one of the approved forms below.

Payment method: Cash Check / Money Order Credit/Debit Card

Payment is due upon submission. Unpaid balances may incur a late fee of per month after 30 days until paid. All costs of collection, including reasonable attorney fees, shall be the responsibility of the requester when permitted by law.

Term and Termination

This request is effective upon receipt by the Office and remains in force until the record is delivered and all obligations are satisfied. The requester may revoke this request in writing; the Office may terminate processing if information is found to be fraudulent, incomplete, or if statutory restrictions prohibit release. Written revocation must be received no less than days prior to delivery to be effective.

Confidentiality

Information contained in vital records is protected by statute and administrative regulation. The Office will disclose only those records or data permissible under law. The requester agrees not to use any record obtained for unlawful purposes and to comply with all restrictions on dissemination, retention, and publication of records.

Processing and Delivery

Standard processing generally occurs within 5–10 business days from receipt of a complete request and payment. Expedited processing is available when offered by the Office and may require an additional fee.

Mail to address on file Pick up in person (ID required) Other

Governing Law

This request and any resulting disclosure of records shall be governed by the laws and administrative rules applicable to vital records in the jurisdiction maintaining the records, including penalties for misuse or misrepresentation.

Entire Agreement

This form, together with any attachments, constitutes the entire written agreement between the requester and the Office with respect to this request and supersedes all prior communications, representations, or agreements, whether oral or written.

Certification

Under penalty of perjury, I certify that the information provided on this form is true and correct to the best of my knowledge and that I am entitled to receive the requested record under applicable law. I understand that willful falsification of a material fact may subject me to criminal penalties.

Are you requesting on behalf of another person? Yes No

Sign Now