www.michigan.gov/mdch APPLICATION FOR A CERTIFIED COPY SENIOR CITIZEN MICHIGAN BIRTH RECORD APPLICANT (PERSON REQUESTING RECORD) PLEASE PRINT CLEARLY AND LEGIBLY Driver=s License or State Identification #: Applicant=s Name: 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. REQUESTED BIRTH RECORD INFORMATION (See back for details) STATE FILE NUMBER: __________________ If you cannot provide all of the following information, we may not be able to locate the record. NAME AT BIRTH First PLACE OF BIRTH: Last 9 Adoption 9 Legal Name Change Hospital DATE OF BIRTH (mm/dd/yyyy) GENDER 9 Male 9 Female First Middle IF THE PERSON ON RECORD IS ADOPTED OR HAS HAD A LEGAL NAME CHANGE (OTHER THAN MARRIAGE) PLEASE INDICATE THAT NAME HERE (If Known) Middle City Last County FATHER=S = NAME: MOTHER=S NAME = BEFORE FIRST MARRIED: First Middle First Last Middle Last Please provide any additional information that would help us locate the record, such as other names that the child or mother have used. PLEASE INDICATE PURPOSE FOR REQUESTING RECORD: Do you know if a birth record has ever been issued? 9 Yes 9 No ARE YOU ELIGIBLE TO REQUEST AND RECEIVE THIS BIRTH RECORD? PLEASE CHECK THE BOX THAT APPLIES TO YOU ELIGIBILITY: Michigan law limits who can request and receive a certified copy of a Michigan birth record. In order to qualify for the special Senior Citizen fee, you must be age 65+ requesting your own birth record. Are you the PERSON NAMED ON THE RECORD and are you age 65 or older? 9 YES 9 NO If no, please use regular birth application form * If the applicant=s name is different than the name as it appears on the requested birth record, provide information required below: Different due to marriage, indicate date of marriage: ____________________ and place of marriage (state): _____________________________ Or different for another reason, please explain: 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. K APPLICANT=S SIGNATURE: (Sign Here) = ___________________________________________________________________________________ MUST BE SIGNED, PHOTO IDENTIFICATION PROVIDED AND SEARCH FEE PAID IN ORDER TO PROCESS REQUEST SENIOR CITIZEN BIRTH RECORD REQUEST FEES AGE 65+ REQUESTING YOUR BIRTH RECORD Search (Non-Refundable) One Certified Copy $ 7.00 $ _________ Additional Certified Copies (Each) $ 12.00 $ EXPEDITED A RUSH@ SERVICE @ (See back for details) $ 10.00 $ TOTAL ENCLOSED: (Additional) DCH-0569-BX Rev 3/9/06 By Authority of MCL 333.2882(1)(a)(b) and MCL 333.2891(1-4)(8) $ 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. * EXPEDITED (RUSH) SERVICE: Applies to standard three-year searches. Not available for extra year searches. 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 Building, 3rd 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 BIRTH RECORD * Please Send Photocopies - Not Original Documents * PROCESSING TIMES For mail-in orders, please allow at least seven days from the time you mail your application until it is received in the Vital Records Office. This will account for the mail time and time in our Accounting Division, prior to our receipt of the request. NOTE: The listed processing time begins when the Vital Records Office receives your application and it is keyed into the system. Under Michigan law, birth records are restricted documents, and a current valid, photo identification is required in order to establish eligibility to request and/or receive one (except for a birth record that is at least 100 years old). 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. Individuals under the age of 15 are unable to request a copy of their own birth record. REGULAR SEARCH - If the birth year is 1906 to the present, your request will be processed within 4 weeks. If the birth year is prior to 1906, the processing time will be 1-3 months. At least one of the following photo ID=s: = < < < * EXPEDITED (RUSH) SEARCH - If the birth year is 1906 to the present, and you pay $10.00 for an "EXPEDITED (RUSH) SEARCH" (in addition to the regular search fee), your request will be processed within 2 weeks. If the birth year is prior to 1906, the processing time will be 3 weeks for an expedited rush search. This service is not available for extra year searches. < < 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 Or, if you do not have one of the above, at least one of the following photo ID=s, with stated supporting documents: = 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 IF EXPEDITED (RUSH) SEARCH MAIL TO: Vital Records RUSH PO Box 30721 Lansing MI 48909 FOR ADD=L INFO: = (517) 335-8666 < < 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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