Full Text
P A G E 1 O F 2 AN OK A CO U N TY V I TA L R E C O RDS 0 3 / 2 02 5 Birth Certificate Request The law requires you to provide information to order a birth certificate, Minnesota Statutes, section 144.225, subdivision 7, and Minnesota Rules, part 4601.2600. It is against the law to provide false information to get a birth certificate. You may be subject to fines, jail time or both. Minnesota Statues, section 144.227 and section 609.02, subdivisions 3 and 4. Information to find the requested birth record Child/Subject Child/subject first name Child/subject middle name Child/subject last name Name suffix Date of birth (MM/DD/YYYY) Sex ☐ Female ☐ Male Minnesota city of birth Minnesota county of birth State of birth MN Parents Parent one first name Parent one middle name Parent one last name Last name before 1st marriage Name suffix Parent two first name Parent two middle name Parent two last name Last name before 1st marriage Name suffix Requester - person completing this application Requester Requester full name Date of birth (MM/DD/YYYY) Daytime phone (10-digit) Requester street address Apt/Unit # Email City State Zip code REQUIRED — Check the boxes below that describe your relationship to the subject of the record: Marital status is important. Records of children born to married parents are “public”. That means that the certificate is available to those listed in items 1 – 18 below. Records of children born to single mothers are “confidential” unless the mother chose to make the record public at the time of birth. Only the persons listed below in items 19 – 23 may obtain confidential birth certificates. “Public” birth certificates are available to individuals who meet any of the legal requirements in items 1-18 1. ☐ A parent named on the subject’s record 4. ☐A child of the subject 2. ☐A grandparent of the subject 5. ☐ A grandchild of the subject 3. ☐ A great grandparent of the subject 6. ☐A great-grandchild of the subject 7. ☐ Spouse of the subject (You must be the current spouse) 8. ☐ I am the subject; I am requesting my own birth record 9. ☐ The legal custodian, guardian, or conservator of the subject (we need a certified copy of the court order that names you) 10. ☐ The health care agent for the subject (we need a valid “health care power of attorney” document) 11. ☐ Subject’s personal representative (we need a notarized statement that says you need the birth certificate to administer the estate) 12. ☐ Successor of the subject (subject is dead) (we need a notarized statement that says you need the birth certificate to administer the estate) 13. ☐ Proof that you need a birth certificate for the determination or protection of a personal or property right 14. ☐ Adoption agency — to complete post-adoption search (we need a copy of your Employee ID) 15. ☐ Local/state/tribal or federal governmental agency (we need a copy of your Employee ID) (Best practice: wait for family to verify the record). 16. ☐ Attorney – I represent the subject, or a person listed in items 1-14 above. If you are a NON-Minnesota attorney, attach a copy My Minnesota Attorney License Number is: of your attorney license. 17. ☐ Pursuant to a valid, certified copy of a U.S. court order (not a subpoena) releasing the certificate 18. ☐ I have a signed statement from a person above; it specifies the subject’s full name, date of birth, parents’ names, the signer’s relationship to the subject of the record and it authorizes me to obtain the certificate. “Confidential” birth certificates are available only under the conditions, or to the person, in items 19-23 19. ☐ Parent named on the subject’s record 20. ☐ The legal custodian, guardian, or conservator of the subject (you need a certified copy of a court order naming you) 21. ☐ The subject, when 16 years old or older 22. ☐ Representatives of Minnesota programs that administer child support, medical assistance, MinnesotaCare, and services under Minnesota Statutes, sections 124D.23; Minnesota Statutes, chapter 260E; and, tribal child support programs, Minnesota Statutes, section 144.225, subdivision 2, paragraph (we need a copy of your Employee ID) 23. ☐ Pursuant to a valid, certified copy of a U.S. court order (not a subpoena) releasing the certificate ---PAGE BREAK--- P A G E 2 O F 2 AN OK A CO U N TY V I TA L R E C O RDS 0 3 / 2 02 5 B I R T H C E R T I F I C A T E R E Q U ES T REQUIRED – Sign this form in front of a notary public I certify that the information provided on this application is correct and complete to the best of my knowledge. Requester’s signature (Signature must match the name of the requester on page one.) Notary Stamp/Seal Notary Signed or attested before me on: day of , 20 Printed name of notary public Notary public signature My commission expires Fees and certificate(s) request Fee First birth certificate $26 $26 Additional birth certificates # of extra copies $19 each Veteran’s Affairs (VA) birth certificate (for VA purposes only) # of copies $0 Processing Standard — request processed in the order received $0 Expedite — request handled ahead of standard requests (doesn’t include delivery) $20 Anoka County Vital Records is not responsible for deliveries that do not require a signature. For delivery outside the United States, you must supply a prepaid express delivery envelope with your application. Total due Fees are due with the application and are non-refundable. Payment method ☐ Check Check # Make check or money order payable to Anoka County. DO NOT SEND CASH. Checks returned for non-payment will result in a $30 charge to ☐ Money order Money order# you. You could also face civil penalties. Send your application and payment to: Anoka County Office Use Only: Vital Records 2100 3rd Ave Anoka MN 55303 ID Viewed ID # DCN # Deputy If you have questions, contact Anoka County Vital Records at or call [PHONE REDACTED].