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Park County Clerk & Recorder 856 Castello Ave, P.O. Box 220 Fairplay, CO 80440 (719) 836-4225 (719) 836-4348 fax Application for Certified Copy of Birth Certificate Requestor Information Print name of person making request First Middle Last Reason for request Mailing address City State Zip Daytime Phone Physical Address City State Zip Alt Phone Number Pursuant to Colorado Revised Statues, 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 imprisonment in the county jail for not more than one year or both such fine and imprisonment (CRS 25-2-118). PLEASE RETURN YOUR REQUEST WITH A PHOTOCOPY OF YOUR DRIVER’S LICENSE, STATE ID OR PASSPORT (To view the full list of primary and secondary identification, please visit www.cdphe.state.co.us/certs) By signing below, I have read and understood that there Relationship to Registrant Today’s Date are penalties for obtaining a record under false pretenses. (person named on certificate) Registrant Information Information about person whose birth certificate is being requested - please type or print. Full Name at Birth First Middle Last Date of Birth Month / Day / Year Is this person deceased? Yes No If yes, date State Where Death Occurred: (Please provide certified copy of death certificate) Place of Birth City County State (Colorado Only) Full Name of Father First Middle Last Full name of Mother First Middle Maiden Last Name (name prior to first marriage) Check here if you are requesting a certificate of stillborn PAYMENT BY CASH or MONEY ORDER ONLY Cost of certificates: $20.00 for 1st copy (or search when no record found $ $13 for each additional copy of same record ordered at same time $ Total $ Number of standard copies Total number of copies