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COLORADO BIRTH CERTIFICATE REQUEST Colorado has birth records for the entire state since 1910. Birth certificates are also available from the county office(s); for all county locations visit http://www.colorado.gov/cdphe REQUIREMENTS This request must be completed in full. Please type or print clearly. Enclose a copy of a current driver’s license, passport or State identification (see reverse side). Enclose appropriate fees Person requesting to receive a birth certificate must sign below. Proof of Relationship is required (Parents and Registrant excluded) Enclose a copy of the death certificate if the person is deceased. Requestor Information (Please Print) Name of Person Making Request First Name Middle Last Email: Mailing Address Street Apt # City State Zip Daytime Phone ( ) Physical Address Street Apt# City State Zip Alt Phone Number ( ) Relationship to Registrant* (person named on certificate) *see reverse side Self Parent Grandparent Step-parent Sibling Spouse Child Stepchild Legal guardian Legal representative Reason for Request: Newborn Travel/Passport Records School Insurance Registrant Information (Please Print) Person listed on the birth certificate. **If adopted, provide adoptive information and see special service on the bottom of the reverse side.** Full Name at Birth First Middle Last Date of Birth Month Day Year Is this person deceased? Yes No If yes, you must provide a copy of the death certificate Place of Birth City County State Colorado ONLY Full Name of Mother or Parent A First Middle LAST NAME PRIOR TO FIRST MARRIAGE Full Name of Father or Parent B First Middle LAST NAME PRIOR TO FIRST MARRIAGE Pursuant to Colorado Revised Statutes, 1982, 25-2-118 and as defined by Colorado Board of Health Rules and Regulations, applicant must have a direct and tangible interest in the record requested. The penalties for obtaining a record under false pretenses include a fine of not more than $1,000.00, or impris- onment in the county jail for not more than one year or both such fine and imprisonment (CRS 25-2-118). By signing below, I have read and understand that there are penalties for obtaining a record under false pretenses. Today’s Date Charges: (FEES NON-REFUNDABLE) $25.00 for $20.00 for each additional certificate of the same record ordered at the same time ***Add 150th Colorado Anniversary logo (free of charge) Please check your shipping method: (certificates can also be picked up in office) Total Charges SIGN HERE Apply in person: Monday-Thursday 8:00 am to 4:00 pm Phone: [PHONE REDACTED] Fax: [PHONE REDACTED] Elbert County Public Health 75 Ute Ave / PO Box 201 Kiowa, CO 80117 **Email completed applications to [EMAIL REDACTED]** To pay with credit card, check here: *Credit card convenience charge varies based on total amount* *staff will call you to collect that payment via phone once the request is processed* FOR OFFICE USE ONLY PAYMENT: CASH $12.00 PRIORITY MAIL: 2 day shipping (check, money order, cash, credit card) *Within the continental U.S. Clear Form ---PAGE BREAK--- Proof of Relationship If your name is not listed on the birth certificate, proof of relationship is required before the birth certificate will be issued (e.g. marriage certificate, birth certificate, court orders). Certified Birth certificates may be issued to: • The registrant (person named on the certificate) • Spouse • Parents • Siblings • Adult children • Stepparents • Legal guardian Legal representatives of any of the above must present proof of client relationship For a complete list visit: http://www.colorado.gov/cdphe/vitalrecords Proof of Identity ◄ACCEPTED ID DOCUMENTS ► PRIMARY LIST Submit one of the following. No expired documents accepted. OR SECONDARY LIST Submit two of the following ONLY if you do not have a document listed under the Primary List. Documents expired more than six months will not be accepted. WE CANNOT ACCEPT THE FOLLOWING: Alien Registration Receipt/Permanent Resident Card Certificate of U.S. Citizenship Jail Temporary Inmate ID: Denver and Pueblo county Colorado Department of Corrections ID card CO Temporary Driver’s license / State ID (must be current) Department of Human Services Youth Corrections ID Employment Authorization Card (I-766) Foreign Passport Government Work ID Job Corps ID Photo Driver’s license / Photo ID Card (DMV U.S. only) School, University or College ID Card (must be current) Temporary Resident Card U.S. B1/B2 Visa card with I-94 U.S. Certificate of Naturalization U.S. Citizenship ID Card (I-197) U.S. Military ID card U.S. Passport U.S. Merchant Mariner ID / Book Acknowledgment of Paternity document(Colorado only) Birth Certificate of Applicant (U.S.A only) Court order of adoption or name change Colorado craft or trade license DD-214 Divorce Decree (U.S.A only) Hospital birth worksheet (for infants under 6 months) Hunting or Fishing License (must be current-Colorado only) IRS-TIN card Marriage license (U.S.A only) Medicare Card Foreign or International Driving License (with photo) Mexican voter registration card Motor vehicle registration or title (U.S.A only) Pilot license Selective Service Card (U.S.A only) Social Security Card State or federal prison or corrections card Weapon or gun permit (U.S.A only) Work ID, Paycheck Stub (within 3 months) or W-2 (Last tax year) Any Expired document from the Primary List (cannot be expired more than 6 months) Matricula Consular Card Novelty ID Card Non-expiring Identification Cards (unless issued in last 5 years) Souvenir birth certificates Out-of-StateTemporary Driver’s license or Temporary State ID Medicaid card / WIC If you cannot provide acceptable identification, it is suggested that you ask a spouse, parent, grandparent, sibling, or adult child, who can provide appropriate identification, to request the certificate. **OPTION AVAILABLE FOR ADOPTIONS** Only an adoptive parent or adopted person is eligible for this special service. ONLY sign below if you wish the statement “ISSUED PURSUANT TO ADOPTION” to appear on the birth certificate which indicates this person is adopted. Number of copies to be issued with “Issued pursuant to adoption” requested: Signature of: adopted person adoptive parent Sign Here