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Revised 10-09 NOTICE: STATE LAW PROVIDES PENALTIES FOR PERSONS WHO WILLFULLY AND KNOWINGLY USES OR ATTEMPTS TO USE OR FURNISH TO ANOTHER FOR USE, FOR ANY PURPOSE OF DECEPTION, ANY CERTIFICATE, RECORD, REPORT, OR CERTIFIED COPY MADE, ALTERED, AMENDED OR MUTILATED. (50-15-114 MCA) BUTTE-SILVER BOW CLERK AND RECORDER’S OFFICE REQUEST FOR BIRTH CERTIFICATES PLEASE READ THESE INSTRUCTIONS CAREFULLY WHO CAN ORDER A BIRTH CERTIFICATE Only those authorized by 50-15-121 MCA, and 37.8.126 ARM which includes the registrant (14 years old or older), the registrant’s spouse, children (with proof of relationship), parents, grandparents (with proof of relationship) a caretaker relative, guardian, an authorized representative or those who provide documentation showing it is needed for determination or protection of the individuals personal or property rights. Proof of relationship, guardianship, caretaker relative or authorization is required to obtain a certified copy of a birth record. Step-relatives, in-laws, aunts, uncles, cousins, ex-spouses, and a natural parent of an adoptive child are not eligible to receive a certified copy of a birth certificate. IDENTIFICATION IS REQUIRED The person signing the request must provide an enlarged legible photocopy of both sides of their valid driver’s license or other legal picture identification with a signature or the requestor must have this application notarized. REQUIRED IDENTIFICATION PICTURE ID WITH A SIGNATURE OR TWO FORMS OF ID – ONE MUST HAVE A SIGNATURE OR • Drivers license • State ID Card • Passport • Military ID Card • Tribal • Social Security card • Work ID card • Car registration/insurance • Doctor/Medical record • Fishing License • US Military DD214 • Utility bill with a current address • Voter Registration card • Credit/Debit/ATM card • School ID card • Library card • Insurance record • Pay stub • Traffic/pawn ticket • Court record • Year book Notarized Montana Office of Vital Statistic Statement to Identify certified Birth or Death Certificate Applicant Form (you must provide the original letter, not a photocopy or faxed copy) Have authorized family member that has an ID order the certificate If a picture ID with a signature is not available, two other forms of identification are required, one MUST have a signature. IMPORTANT: If the identification requirement is NOT met or if the application is incomplete, your request will be returned and significant delays in processing your order may occur. FEE (All fees must be U.S. funds) CERTIFIED COPIES OF A BIRTH CERTIFICATE: cost $5.00 for each copy (non-refundable) INFORMATIONAL COPIES OF A BIRTH CERTIFICATE may be issued to anyone as long as the birth occurred 30 years prior to the date of application; the cost is $0.50 (non-refundable) SEARCHES: $0.50 for each year searched (non-refundable) Please complete the following information: FULL First, Middle and Last Name on birth certificate: Has name ever been changed other than marriage: No Yes-if so original name: Date of Birth: Place of Birth: (City or county) Mother’s Full Maiden Name: Father’s Full Name: Your relationship to the certificate holder: (self, mother, father, etc) Reason the birth certificate is needed: Number of copies: Applicant’s Signature: Mailing or delivery address: Name: Address: City, State, Zip: Daytime Telephone Number: RETURN FORM(S), MONEY ORDER OR CASH (only) & STAMPED SELF ADDRESSED ENVELOPE TO: BSB CLERK & RECORDER’S OFFICE RM 208 155 WEST GRANITE BUTTE, MONTANA 59701 Notary (if needed) Personally appeared before me and whose identity I proved on the basis of satisfactory evidence to be the signer of the above instrument. Subscribed and sworn to before me this day of 20___ Official Use Only SEAL Signature: Printed Name: Notary Public in and for the State of Residing at My commission expires Date: Trk (red): Cert Ser Amount: