Full Text
Page 1 of 1 STATE AND COUNTY VITAL RECORDS OFFICES 9/2021 Statement to Identify An applicant who does not have an acceptable ID may ask a witness to complete this form. The witness who completes this form swears to the requester’s identity and how they know the requester. To request and get a Minnesota birth or death certificate, a requester must have an acceptable ID. And the requester must have a legal right to the certificate. If the requester does not have an acceptable ID, a witness who has known the requester at least two years may confirm the requester’s identity. Minnesota Rules, part 4601.2600, subparts 5, 6, and 7. It is against the law to give false information to obtain a certified vital record. You may be subject to fines, jail time or both. Minnesota Statutes, section 144.227 and section 609.02, subdivisions 3 and 4. Witness information – person who has known the “Requester” for two or more years (Please print) Witness first name Witness middle name Witness last name Witness home or business address information Street address City State Zip Code™ Witness phone number (10-digit) Witness email address Witness date of birth (mm/dd/yyyy) What is your relationship to, or how do you know the requester? I solemnly swear that I have known the requester named below for years. Requester information – person applying for birth or death certificate (Please print) Requester first name Requester middle name Requester last name Requester date of birth (mm/dd/yyyy) Name of the subject on the birth or death record wanted by the requester (Please print) Subject’s first name Subject’s middle name Subject’s last name Subject’s date of birth or death (mm/dd/yyyy) Witness, will you and the requester go to the county vital records office together? ☐YES We will go to the county vital records office together. I (the witness), will sign this statement in front of the county registrar and show identification. ☐NO I will NOT go to the county vital records office with the requester. I will sign this statement in front of a Notary Public and give this statement to the requester. Signature of witness Date signed (mm/dd/yyyy) Notary Public Signed or attested before me on day of Notary stamp/seal Printed name of notary public Notary public signature My commission expires Do you have questions? County Vital Records Office Contacts Office of Vital Records Help Desk – [PHONE REDACTED]