State of Florida

Department of Health
Office of Vital Statistics
APPLICATION FOR FLORIDA BIRTH RECORD
Requirement for ordering: If applicant is self, parent, guardian, or legal representative, then the applicant must complete this application and provide a copy of a valid
photo identification. If applicant is not one of the above, the Affidavit to Release a Birth Certificate must be completed by an authorized person and submitted in addition to
this application form. Acceptable forms of identification are the following: Driver’s License, State Identification Card, Passport, and/or Military Identification Card.
FIRST MIDDLE LAST SUFFIX
CHILD’S FULL NAME AS
SHOWN ON BIRTH RECORD

FIRST MIDDLE LAST SUFFIX

IF NAME WAS CHANGED SINCE
BIRTH, INDICATE NEW NAME

MONTH DAY YEAR (4-DIGIT) STATE FILE NUMBER (If known) SEX
DATE OF BIRTH

HOSPITAL CITY OR TOWN COUNTY

PLACE OF BIRTH

FIRST MIDDLE LAST SUFFIX

MOTHER’S MAIDEN NAME
(Name before marriage)

FIRST MIDDLE LAST SUFFIX

FATHER’S NAME

A BIRTH RECORD SEARCH REQUIRES ADVANCE PAYMENT OF A NON-REFUNDABLE SEARCH FEE OF $9.00 AND VALID PHOTO IDENTIFICATION.
A Computer Certification requires the $9.00 fee which entitles the applicant to one registered birth (1917 to present) or
if a record is not found, a certified “No Record Found” statement will be issued.
X =
 The Computer Certification is recognized and accepted by ALL State and Federal Agencies. $9.00
 If birth occurred prior to 1917 select Computer Certification for $9.00.
 Normal processing time is 3-4 business days, provided the record and application are complete and in order.
A Photocopy Certification (In place of a Computer Certification) requires an additional charge of $5.00 and
includes the $9.00 search fee. Normal processing time is approximately 10 business days.
$14.00 X =
Definitions of the two types of Certifications are on the reverse side.
Additional Computer Certifications:
$4.00 for each subsequent Computer Certification $4.00 X =

Additional Photocopy Certifications:

$4.00 for each subsequent Photocopy Certification $4.00 X =

Additional Years to be Searched:

$2.00 for each additional year. The maximum additional year search fee is $ 50.00 regardless of the total $2.00 X =
number of years to be searched. (Indicate the range of years to be searched in the 2nd Box.)
RUSH ORDERS (Optional): RUSH Fees are an additional $10.00.
If you desire RUSH service, mark the outside of your envelope “RUSH” (Processing time is 1-2 business days) Check here for rush order =

TOTAL AMOUNT ENCLOSED: Check or Money Order Payable to: Vital Statistics. (DO NOT SEND CASH) ENCLOSE COPY OF VALID PHOTO
International payments should be made by Cashiers Check or Money Order in U. S. Dollars. IDENTIFICATION OR YOUR ORDER
Florida Law imposes an additional service charge of $15.00 for dishonored checks. WILL NOT BE COMPLETED

APPLICANT INFORMATION
Any person who willfully and knowingly provides any false information on a certificate, record or report required by Chapter 382, Florida Statutes, or on any application or affidavit, or who obtains
confidential information from any Vital Record under false or fraudulent purposes, commits a felony of the third degree, punishable as provided in Chapter 775, Florida Statutes.

Applicant’s Name FIRST MIDDLE LAST (INCLUDING ANY SUFFIX)

TYPE OR PRINT

ADDRESS (INCLUDE APT. NO., IF APPLICABLE) CITY STATE ZIP CODE

HOME PHONE NUMBER RELATIONSHIP TO REGISTRANT SIGNATURE OF APPLICANT

WORK PHONE NUMBER

Applicant's Signature

IF ATTORNEY, PROVIDE BAR/PROFESSIONAL LICENSE NO. IF ATTORNEY , PROVIDE NAME OF PERSON YOU REPRESENT AND THEIR RELATIONSHIP TO REGISTRANT

IF THE CERTIFICATION IS TO BE MAILED TO ANOTHER PERSON OR ADDRESS USE THE SPACES BELOW TO SPECIFY SHIP TO NAME AND ADDRESS.
SHIP TO NAME FIRST MIDDLE LAST (INCLUDING ANY SUFFIX)
TYPE OR PRINT

HOME PHONE NUMBER SHIP TO STREET ADDRESS (AND APT. NO. IF APPLICABLE)

WORK PHONE NUMBER CITY STATE ZIP CODE

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 INFORMATION AND INSTRUCTIONS FOR BIRTH RECORD APPLICATION
COMPUTER CERTIFICATION: The Computer Certifications are accepted by all State and Federal Agencies and used for any type of travel.
3-4 business days is the Normal Response time, provided the record and application are complete and in order.
A Computer Certification has two different formats which are:
 A certification of a registered birth (2004 to Present), supplies the following facts of birth: Childs Name, Date of Birth, Sex, Time, Weight, Place
of Birth (City, County and Location) and Parents Information.
 A certification of a registered birth (1917 to 2003), supplies the following facts of birth: Childs Name, Date of Birth, Sex, County of Birth and
Parents Name.
 If the birth occurred prior to 1917, only photocopies are available. When ordering, select Computer Copy for $9.00. Records are available from
1865 to present but are limited from years 1865-1916.
PHOTOCOPY: A photocopy is a certificate of the registered birth on file. Photocopies of birth certificates are certified documents. Normal response time
for photocopies is approximately 10 business days.
AVAILABILITY: Birth registration was not required by state law until 1917, but there are some records on file dating back to 1865. Birth records under
seal by reason of adoption, paternity determination or court order cannot be ordered in this manner. For a record under seal, write to ATTN:
Records Amendment Section at the address below.
ELIGIBILITY: Birth certificates can be issued only to:
1. Registrant (the child named on the record) if of legal age (18)
2. Parent(s) listed on the Birth Record
3. Legal Guardian (must provide guardianship papers)
4. Legal representative of one of the above persons
5. Other person(s) by court order (must provide recorded or certified copy of court order)
In the case of a deceased registrant, upon receipt of the death certificate of the decedent, a certification of the birth certificate can be issued to the
spouse, child, grandchild, sibling, if of legal age, or to the legal representative of any of these persons as well as to the parent.
Any person of legal age may be issued a certified copy of a birth record (except for those birth records under seal) for a birth event that occurred
over 100 years ago.
REQUIREMENT FOR ORDERING: If applicant is self, parent, legal guardian or legal representative, then the applicant must provide a
completed application along with a copy of a valid photo identification. If legal guardian, a copy of the appointment orders must be
included with your request. If legal representative, your attorney bar number, and a notation of whom you represent and their relationship
to the registrant must be included with your request. If you are an agent of local, state or federal agency requesting a record, indicate in the
space provided for “relationship” the name of the agency. Acceptable forms of identification are the following: Driver’s License,
State Identification Card, Passport and/or Military Identification Card.
If not one of the above, you must complete this application and have a notarized Affidavit to Release A Birth Certificate (DH Form 1958,
2/03) submitted with your application for the birth record along with a copy of a valid photo identification.
RELATIONSHIP TO REGISTRANT: A person ordering his or her own certificate should enter "SELF" in this space. Also, explain if name
has been changed; married name, name changed legally (when and where), etc. Others must identify themselves clearly as eligible
(see ELIGIBILITY above).
NONREFUNDABLE: Vital record fees are nonrefundable, with one exception. Fees paid for additional copies when no record is found will be
refunded upon written request.
APPLICANT’S SIGNATURE: Is required, as well as his/her printed name, residence address and telephone number.
OPTIONS FOR RUSH SERVICE:
 CREDIT CARDS: The state office currently does not accept credit cards but there is a private firm that accepts such charges
and transfers the order to Vital Statistics for a fee of $7.00 plus a $10.00 Rush Fee charged by the State Office. You may
telephone 1-877-550-7330 or you may fax your request to the private firm at 1-877-550-7428. In any event, you may dial (904)
359-6900 and follow the prompts on the telephone system to be transferred free of charge to the contracted vendor. If you have
any questions please call the Office of Vital Statistics at (904) 359-6900, Ext. 9000 and our Client Services personnel will be able
to assist you.
 MAIL IN: An order with an envelope marked RUSH with a $10 rush fee enclosed, provided the record and application are complete
and in order, will be processed before the normal processing time. This does not include birth records requiring an amendment action. If
an amendment action is necessary, additional processing time will be required.

WALK-IN SERVICE: Is available at 1217 Pearl Street, Jacksonville, Florida, between 8:00 am – 4:30 pm. Orders prepaid by Noon
may be picked up after 3:30 p.m. Orders prepaid after Noon may be picked up after 10:00 a.m. the next workday. Each request must be
accompanied by picture identification Certifications for photocopies rush service requires an additional fee of $10.
TIME OF BIRTH: This item was not collected on the birth events between 1949 – 1969.

MAIL THIS APPLICATION WITH PAYMENT TO

STATE OFFICE OF VITAL STATISTICS
ATTN: CLIENT SERVICES
P.O. BOX 210
Jacksonville, FL 32231-0042
PLEASE VISIT OUR WEBSITE
http://www.doh.state.fl.us/planning_eval/vital_statistics/index.html

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