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CITY OF LEWISTON, MAINE APPLICATION FOR A CERTIFIED COPY OF A BIRTH RECORD $15.00 for first copy, $6.00 for each additional copy of the same record purchased at the same time MUST INCLUDE A PHOTOCOPY OF A GOVERNMENT ISSUED PHOTO I.D. Make check payable to “City of Lewiston” **PLEASE PRINT** Full Name on Birth Record: City of Birth: Date of Birth: Father’s Full Name: Mother’s Full Maiden Name: Your Name: Today’s Date: Your Complete Mailing Address: Email: Your Phone Number: Your Relationship: Q Self Q Parent Q Spouse Q Child Q Other By signing below, I swear/affirm that the information above is true and correct. Your Signature: How many certified MAIL REQUEST TO: City Clerk’s Office, 27 Pine Street, Lewiston, ME 04240 MUST INCLUDE A PHOTOCOPY OF A GOVERNMENT ISSUED PHOTO I.D. **PLEASE INCLUDE A SELF ADDRESSED STAMPED ENVELOPE** Please note effective July 1, 2010 a 2.5% processing fee will be added to all debit & credit card purchases A $1.00 minimum fee will be charged for all debit and credit card transactions Fax Number: (207) 777-4621 If you are faxing your request please include the following: Signature of cardholder Name as it appears on the credit card Credit Card Date Billing Zip Code