APPLICATION FOR A CERTIFIED COPY MICHIGAN AFFIDAVIT OF PARENTAGE RECORD NOTE: The Michigan Vital Records office has Affidavit of Parentage records that were filed in the Central Paternity Registry with the state since June 1, 1997. If you would like an Affidavit of Parentage record that 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. Affidavit of Parentage records are restricted documents (see Part 4). PART 1: APPLICANT’S INFORMATION Applicant’s State Driver’s License Name:_______________________________________________________ or Identification # _________________________ Mailing Address: ______________________________________ City: ____________________ State: _____ Zip: _________ (Cannot Send to General Delivery) Daytime Phone - Required: ( ) _________________________ Other Phone: ( ) ______________________________ CURRENT VALID GOVERNMENT ISSUED PHOTO ID REQUIRED (See Back for Alternative Documents) PART 2: CERTIFICATION OF INFORMATION PROVIDED By signing this application, I understand that I am agreeing to pay for a search of the State of Michigan Vital Records. This does not guarantee that a record will be found. Statement of Entitlement: Misstating an identity or assuming the identity of another person is subject to criminal penalties, e.g., Michigan Compiled Laws 333.2894(b) and 333.2898 and federal laws relating to falsification in obtaining a birth record. By signing this application, I state that I am eligible to receive this birth record as indicated in the Eligibility Section of this application. ► Applicant’s Signature: _________________________________ Date: __________ IDENTITY THEFT PROTECTION ACT 445.65(1) and 445.69(1) prohibits anyone from obtaining a vital record by misrepresenting a person’s identity or attempting t o use another person’s identifying information. A person who violates this law is guilty of a felony punishable by imprisonment for up to 5 years or a fine of up to $25,000 or both. PART 3: PURPOSE FOR REQUESTING THE RECORD PART 4: ELIGIBILITY - Select the category that qualifies YOU to request and receive the requested Michigan Affidavit record per MCL 333.2882 □ Person named on the record □ Parent named on the record Note: If adopted, only adoptive parents are eligible □ Legal guardian of the person named on the record (Copy of court documented guardianship papers required) □ Legally licensed attorney of subject of the record (Letter on official letterhead required: Must provide state bar number and the name of the person you represent) □ Heir of the deceased person named on the record, and • Relationship to decedent: ________________________ • Decedent’s name at time of death: _________________ • State where death occurred: ______________________ • Date of death (Year): ____________________________ If not a Michigan death, must provide death certificate □ Court of competent jurisdiction (Court order & fee required) PART 5: INFORMATION NEEDED TO FIND AFFIDAVIT OF PARENTAGE RECORD BEING REQUESTED Child’s Full Name at Birth Child’s Date of Birth (mm/dd/yyyy) First Middle Child’s Place of Birth (County) Last Mother’s Name Mother’s Date of Birth (mm/dd/yyyy) First Middle Last Father’s Name Father’s Date of Birth (mm/dd/yyyy) First Middle Last PART 6: FEES - Includes one certified copy or no-find letter Base Fee: Includes One Year Search $34.00 $ 34.00 Additional Certified Copies (Each) ____ x $16.00 $ Additional Years Search (Number of years) ____ x $12.00 $ (when exact year unknown) Indicate years you want searched: _____ _____ _____ EXPEDITED “RUSH” SERVICE (Additional) PAYMENT TO “STATE OF MICHIGAN” $12.00 TOTAL: $ For Accounting Use Only Is your request complete? Don’t forget your ID! American LegalNet, Inc. www.FormsWorkFlow.com PROCESSING TIMES FOR MAIL REQUESTS HAVE YOU ??        PART 1: Print your name and mailing address Cannot send to general delivery addresses Include a telephone number to reach you Enclose proper ID PART 2: Sign your name Do not print. Signature required. PART 3: Fill out purpose for requesting the record PART 4: Indicate your eligibility Provide all necessary documentation PART 5: Complete all items “Unknown” if information unavailable “N/A” if not applicable PART 6: Fees Please total all fees correctly PAYMENT Check or money order made payable to the “State of Michigan” APPLYING IN PERSON LOCATION: Capitol View Building, 3rd Floor 201 Townsend Street Lansing MI 48913 (across from the State Capitol) LOBBY HOURS: 8:00 am - 5:00 pm M-F except for recognized state holidays. REGULAR SEARCH – The processing time for a regular request will be approximately 5 weeks, depending on the volume of requests received. EXPEDITED (RUSH) SEARCH – The processing time for a “rush” request will be approximately 2 weeks, depending on the volume of requests received. ADDITIONAL INFORMATION - If you find that the processing times listed do not meet your needs, please call our Eligibility Unit at 517335-8666 and speak with a customer service representative. They may be able to offer additional help to meet your individual situation. IDENTIFICATION REQUIREMENTS FOR APPLYING IN PERSON OR BY MAIL FOR A MICHIGAN AFFIDAVIT OF PARENTAGE RECORD * Please Send Copies - Not Original Documents * Under Michigan law, Affidavit of Parentage records are restricted documents. To request an Affidavit of Parentage record, a current valid, government issued identification is required in order to establish eligibility. To protect you and the community from identity theft, we require a copy of the applicant’s government issued identification to be presented along with the application. At least one of the following ID’s is required:  Current driver’s license with photo if unexpired, or expired less than one year  SAME DAY SERVICE: Orders at our counter must be placed by 3:00 pm in order to receive same-day service. Additional “rush” fee of $12.00 is required for same-day service and you must allow up to a 2 hour waiting period for the order to be processed. Genealogy requests may take longer. Current state issued photo identification card unexpired, or expired less than one year   Unexpired U.S. or foreign passport  Employment identification with photo, accompanied by a current pay stub or W-2 form PAYMENT: A money order, credit card or cash can be used at our front counter. A personal check can also be used if NOT same-day service.  Department of Corrections photo identification card, accompanied by probation or discharge papers dated within last year  If a currently incarcerated prisoner, a Department of Corrections photo identification card, accompanied by a verification of incarceration by the facility on letterhead  For persons age 15 or older, current student photo ID with either a current report card or current transcript DIRECTIONS: Visit our website at: www.michigan.gov/ vitalrecords or call 517-335-8666. PAYMENT INFORMATION SEARCH FEES ARE NON-REFUNDABLE: Fees are established by state statute. The base fee includes a statewide search of one year and either one certified copy of the record or an official statement that the record is not filed with the state. 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 Michigan Department of Treasury, usually within 3-6 weeks. MAIL APPLICATION TO REGULAR MAIL TO: Vital Records Requests PO Box 30721 Lansing MI 48909 RUSH MAIL TO: Vital Records RUSH PO Box 30721 Lansing MI 48909 www.michigan.gov/vitalrecords 517-335-8666 DCH-0569-AOP Rev 11-2015 By Authority of MCL 333.2882(1)(a)(b) and MCL 333.2891(1-4)(8) U.S. military photo identification or military dependent photo identification with current expiration date ALTERNATIVE DOCUMENTS can be submitted and reviewed by a supervisor if a current, valid government issued ID is not available. If you do not have one of the above, you will need to submit at least three of the following, and one MUST be dated within the last year. Please note we cannot use a Social Security Card or junk mail. Examples might be: expired state or federal photo ID, marriage or divorce certificate, child’s birth record, W-2, paycheck stub, bank statement, voter or car registration, health insurance/Medicaid card, state benefit card, utility bill, doctor/dentist/hospital bill, baptismal certificate, letter from a government agency such as Social Security or the IRS, benefit statement from Social Security, school records, tax records, incarceration records or land/rental agreement. 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. American LegalNet, Inc. www.FormsWorkFlow.com