MAIL OR COUNTER APPLICATION FOR A CERTIFIED COPY MICHIGAN CERTIFICATE OF STILLBIRTH www.michigan.gov/mdch The Michigan Vital Records office issues certificates of stillbirths that occurred in Michigan with information filed after June 1, 2003 with the state. APPLICANT (PERSON REQUESTING RECORD) PLEASE PRINT CLEARLY AND LEGIBLY Applicant=s Name: Driver=s License or State Identification #: Address: City/State: Daytime Phone Required: ( ) Other Phone: ( Zip: ) To protect the privacy of this record, we require PHOTO IDENTIFICATION to be presented along with this application. (See back for details) ARE YOU ELIGIBLE TO REQUEST THIS CERTIFICATE OF STILLBIRTH? ELIGIBILITY: Michigan law limits who can receive a certified copy of a Michigan Certificate of Stillbirth. 9 Parent named on certificate Please check the box that applies to you. 9 Court of competent jurisdiction (Court order attached) INFORMATION NEEDED TO LOCATE THE CERTIFICATE CHILD=S NAME = (First, Middle, Last) MOTHER=S CURRENT NAME = (First, Middle, Last) FATHER=S NAME = (First, Middle, Last) DATE OF DELIVERY (Month, Day, Year) PLACE OF DELIVERY (Hospital, County) 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 certificate of stillbirth record.. By signing this application, I state that I am eligible to receive this certificate of stillbirth 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 FOR ADDITIONAL INFORMATION: Vital Records Requests (517) 335-8666 Mon-Fri 8:00 am - 5:00 pm ET PAYMENT MUST BE MADE IN U.S. FUNDS BY CHECK OR MONEY ORDER PAYABLE TO THE ASTATE OF MICHIGAN@ Search Includes One Certified Copy MAIL APPLICATION AND FEE TO: Vital Records Requests PO Box 30721 Lansing MI 48909 PROCESSING TIME The certificate will be available within 10 days after the required identifying report is received by the state from the hospital or attending physician. $ 26.00 $ _________ Add=l Certified Copies (Each) $ 12.00 $ TOTAL ENCLOSED: $ PENALTIES: Any person who willfully and knowingly makes false application for a stillbirth certificate may be fined not more than $1,000 and/or imprisoned not more than one (1) year. MCL 333.2894(1)(b) DCH-0569-SB Rev 3/9/06 By Authority of MCL 333.2834(8), MCL 333.2882(1)(a) and MCL 333.2891(1-4) American LegalNet, Inc. www.FormsWorkflow.com PAYMENT - NO ORDER WILL BE PROCESSED WITHOUT PROPER FEE SUBMITTED WITH A SIGNED APPLICATION AND PHOTO IDENTIFICATION PHOTO ID REQUIREMENTS FOR APPLYING IN PERSON OR BY MAIL FOR A MICHIGAN CERTIFICATE OF STILLBIRTH RECORD 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. * Please Send Photocopies - Not Original Documents * 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. Under Michigan law, certificates of stillbirth 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@ @ < < Or, if you do not have one of the above, at least one of the following photo ID=s, with stated supporting documents: = < 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 rd Townsend St, Capitol View Building, 3 Floor, Lansing MI 48913 (across from the State Capitol). 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 for payment. Same-day service is not available for Certificates of Stillbirth. 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 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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