DOH: Health Statistics Administration - Birth Certificate Request

Mail-In Form	(Click here for Instructions)
1. Certificate Holder's Name:	(First) (Middle) (Last)
2. Birth Date:	/ / (mm/dd/yyyy)
3. Sex:	Male Female
4. Hospital:
5. City:	Washington, DC
6. Father's Name:	(First) (Middle) (Last)
7. Mother's Maiden Name:	(First) (Middle) (Maiden)
8a. Number of Original Certificate Forms Requested:
$23.00 each		Total Cost: $
8b. Total Amount Enclosed:* *	$
9. Relationship to Certificate Holder:	Self Mother Father Other
10. Signature of Requester:		_____________________________________
11. Date:		_________/_________/_________ (mm/dd/yy)
Mail Certificate(s) to:
12. Name:
13. Address:
14. City/State/Zip Code::
15. Day Phone: (Required)
* Copy of Requester's Photo ID Required. If record is not located a "Certificate of Search" will be issued. Beginning January 1, 2009, all mail-in requests must include a stamped self addressed No. 10 (4 1/8" x 9 1/2") business size return envelope. The DC Treasurer requires that all checks have an address imprinted on them to be accepted for deposit. Starter checks are not accepted.
Instructions to be completed: 1. Print, sign, enclose requestor's photo ID and date the form 2. Enclose check or money order payable to DC Treasurer 3. Mail to: Department of Health Vital Records Division 899 North Capitol Street, NE, 1st Floor Washington, DC 20002 (202) 671-5000
Birth Application Instructions The birth certificate request form contains 12 questions. A separate copy of the request form should be completed for each person whose birth record is being requested. However, multiple copies of a single birth record may be requested on the same form. Items 1-7: Personal information about the certificate holder. Item 8a: Please indicate the total number of original form certificates that you are requesting. To calculate the total cost, multiply the number of requested certificates by $23. The DC Vital Records Division does not process online orders. For your convenience, you can process online requests through VitalChek Network, Inc., an independent company that Vital Records has partnered with to provide you this service. VitalChek can be reached either through its website www.vitalchek.com or by phone at 1 (877) 572 6332. An additional fee is charged by VitalChek for using this service, and all major credit cards are accepted including American Express, Discover, MasterCard or Visa. Item 8b: Please indicate the total amount of money that you are enclosing. If you send your request by mail, please enclose a check or money order payable to the DC Treasurer. The DC Treasurer requires that all checks have an address imprinted on them to be accepted for deposit. Item 9: The relationship of the requester to the certificate holder. Items 10-11: The person who is requesting the certificate(s) must sign and date the request and enclose a photocopy of his or her official picture identification card. Items 12-15: Information about the designated recipient of the certificate(s). After you have printed out and signed your request, mail it with your payment to: Department of Health Vital Records Division 899 North Capitol Street, NE, First Floor Washington, DC 20002 (202) 671-5000 If record is not located a "Certificate of Search" will be issued. Restriction on Access to Birth Certificates: Pursuant to D.C. Official CodeSec. 7-220, the Vital Records Division may issue a certified copy of a birth certificate ONLY to an applicant having a direct and tangible interest in the requested birth certificate. NOTE: This form should be used ONLY by the registrant, a member of his/her immediate family, his/her guardian or legal representative.