MAIL OR COUNTER APPLICATION FOR A CERTIFIED COPY MICHIGAN AFFIDAVIT OF PARENTAGE State File Number (If Known) www.michigan.gov/mdch NOTE: The Michigan Vital Records office has Affidavit of Parentage forms that were filed in the Central Paternity Registry with the state since June 1, 1997. If the Affidavit of Parentage form you are requesting was filed prior to June 1, 1997, please contact the Probate Court in the county where the mother resided at the time of signing or the Probate Court in the county where the child was born. APPLICANT (PERSON REQUESTING AFFIDAVIT OF PARENTAGE RECORD) PLEASE PRINT CLEARLY AND LEGIBLY Applicant=s Name: Driver=s License or State Identification #: Address: City/State: Daytime Phone Required: ( Other Phone: ) To protect you from identity theft, we require PHOTO Zip: ( ) IDENTIFICATION to be presented along with this application. ARE YOU ELIGIBLE TO REQUEST AND RECEIVE THIS AFFIDAVIT OF PARENTAGE RECORD? (See back for details) PLEASE CHECK THE BOX THAT APPLIES TO YOU ELIGIBILITY: Effective March 31, 2003, Michigan law limits who can receive a certified copy of a Michigan Affidavit of Parentage record filed in the Central Paternity Registry since June 1, 1997. You must select which category qualifies you to request and receive the Affidavit of Parentage record. 9 9 9 9 9 Heir of the deceased person named in the Mother named on the Affidavit of Parentage Father named on the Affidavit of Parentage Child named on the Affidavit of Parentage Legal guardian of one of the persons named on Affidavit of Parentage Affidavit of Parentage (Must provide information below) Specify relationship _______________________________ Date of death (Year) ______________________________ (Copy of court documented guardianship papers required) 9 Legal representative of one of the persons named on Affidavit of Parentage (Official letter required; provide your state license number and name the person represented) 9 Court of competent jurisdiction (Court order required) Name at time of death ____________________________ Place of death ___________________________________ (City, County, State) STATEMENT OF ENTITLEMENT: Misstating an identity or assuming the identity of another person is subject to criminal penalties, e.g., Michigan Compiled Laws 333.2882(1)(f)) and 333.2891(1-4) and federal laws relating to falsification in obtaining an Affidavit of Parentage record.. By signing this application, I state that I am eligible to receive this Affidavit of Parentage record as indicated in the Eligibility Section of this application. K APPLICANT=S SIGNATURE: (Sign Here) = ___________________________________________________________________________________ MUST BE SIGNED, PHOTO IDENTIFICATION PROVIDED AND SEARCH FEE PAID IN ORDER TO PROCESS REQUEST (If any birth information is unknown, please indicate A unknown@ @ REQUESTED INFORMATION FOR AFFIDAVIT OF PARENTAGE RECORD NAME AT BIRTH First Middle Last CHILD=S DATE OF BIRTH = (mm/dd/yyyy) First Middle Last MOTHER=S DATE OF BIRTH = (mm/dd/yyyy) First Middle Last FATHER=S DATE OF BIRTH = (mm/dd/yyyy) MOTHER=S = NAME FATHER=S = NAME AFFIDAVIT OF PARENTAGE REQUEST FEES Search (Non-Refundable) Includes One Certified Copy $26.00 $ _______ Additional Copies (Each) $12.00 $ EXPEDITED SEARCH * (Non-Refundable) (In addition to regular search fee) $10.00 Add=l $ TOTAL ENCLOSED: WE CANNOT PROCESS YOUR REQUEST WITHOUT PAYMENT. IF MAILING, PLEASE REMEMBER TO INCLUDE CHECK OR MONEY ORDER. $ American LegalNet, Inc. www.FormsWorkflow.com PAYMENT - NO ORDER WILL BE PROCESSED WITHOUT PROPER FEE SUBMITTED WITH A SIGNED APPLICATION AND PHOTO IDENTIFICATION SEARCH FEES ARE NON-REFUNDABLE: Fees are established by state statute. A search fee covers the cost of a basic 3-year search and includes either one certified copy of the record or an official statement that the record is not filed with the state. A basic search includes the files for the year specified as the birth year, as well as the year before and the year after. REFUNDABLE FEES: Payment for additional copies will be refunded if the search indicated that the record is not filed with the state. A refund check would be mailed to you by the Department of Treasury, usually within 3-4 weeks. TURN-AROUND TIME - For regular or expedited mail requests, please allow at least seven days for mailing and our department=s receipting of your payment. = REGULAR SEARCH - Processing time will be 4 weeks. * EXPEDITED SEARCH - If you pay the expedited search fee (in addition to the regular search fee), a counter request will be processed in 1-3 hours. For a mail request, the processing time will be 2 weeks. APPLYING IN PERSON If you wish to apply in person to order a Michigan vital record, you may do so at the office located at 201 Townsend St, Capitol View rd Building, 3 Floor, Lansing MI 48913. Lobby hours are 8:00 am 5:00 pm. Directions are available by logging onto our website at: www.michigan.gov/mdch or by calling 517-335-8666. A check or money order is preferred, and orders in our lobby must be placed by 3:00 pm in order to request same-day service. An additional fee of $10.00 is required for same-day service orders. Please allow a 2-3 hour waiting period for same-day service. PHOTO ID REQUIREMENTS FOR APPLYING IN PERSON OR BY MAIL FOR A MICHIGAN AFFIDAVIT OF PARENTAGE RECORD * Please Send Photocopies - Not Original Documents Under Michigan law, Affidavit of Parentage records are restricted documents, and a current valid, photo identification is required in order to establish eligibility to request and/or receive one. To protect you and the community from identity theft, we require a copy of the applicant=s photo identification to be presented along with the application. At least one of the following photo ID=s: = < PAYMENT MUST BE MADE IN U.S. FUNDS BY CHECK OR MONEY ORDER PAYABLE TO THE: < < ASTATE OF MICHIGAN@ @ < < IF REGULAR SEARCH MAIL TO: Vital Records Requests PO Box 30721 Lansing MI 48909 Or, if you do not have one of the above, at least one of the following photo ID=s, with stated supporting documents: = < < IF EXPEDITED (RUSH) SEARCH MAIL TO: Vital Records RUSH PO Box 30721 Lansing MI 48909 Michigan driver=s license unexpired or expired for not more than one year State of Michigan identification card unexpired or expired for not more than one year Driver=s license or official identification card issued by another state in the U.S., jurisdiction or territory, unexpired, or expired for not more than one year. Unexpired U.S. or foreign passport U.S. military identification, military dependent identification or veteran=s identification < < Employment identification with photo, accompanied with a pay stub or W-2 form School, university or college identification with photo, accompanied with a report card or other proof of current school enrollment Michigan driver=s license expired for more than one year, accompanied by a motor vehicle registration or title, a bridge card, MI-Health card, inmate probation or discharge documents, a veteran=s DD-214, or an original copy of an Affidavit of Parentage Department of Corrections identification card, accompanied by probation or discharge papers If an inmate currently incarcerated, a Department of Corrections identification card, accompanied by a verification of incarceration by the facility on letterhead FOR ADD=L INFO: = (517) 335-8666 < DCH-0569-AOP Rev 3/9/06 By Authority of MCL 333.2882(1)(f) and MCL 333.2891(1-4) If you are unable to provide any of the above mentioned forms of identification, please contact the Michigan Vital Records Office at 517-335-8666 and speak with a customer service representative. 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