IN THE CIRCUIT COURT OF ______________________________ COUNTY, MISSOURI Judge or Division: Case Number: Petitioner: Petitioner’s Address: vs. Respondent: Department of Health and Senior Services Bureau of Vital Records Respondent’s Address: Missouri Department of Health and Senior Services Bureau of Vital Records P.O. Box 570 Jefferson City, MO 65102-0570 (Date File Stamp) Petition for Establishing Record of Birth Petitioner has applied to the Bureau of Vital Records, State Registrar, for a delayed certificate of birth. The application having been rejected, Petitioner states as follows: 1. That Petitioner was born in this state on ________________ (date) in _____________________ County; 2. That no certificate of birth of Petitioner can be found in the Department of Health and Senior Services or the office of any local custodian of birth certificates; 3. That diligent efforts by the Petitioner have failed to obtain the evidence required in accordance with Section 193.105 RSMo, and regulations adopted thereto; and 4. That the State Registrar has refused to register a delayed certificate of birth. In further support of this petition, Petitioner alleges: The following documents are attached to this Petition and are incorporated herein by reference: * A statement from the Bureau of Vital Records indicating the reasons for not registering a delayed certificate of birth; * A copy of the completed Application to Record Birth submitted to the Bureau of Vital Records; * A copy of the completed Supporting Affidavit attached to the application; * Copies of the documents submitted with the application evidencing petitioner’s name, date and place of birth. Petitioner requests the Court to issue an order establishing a record of the date and place of birth, parentage and other such findings as may be required and to issue an order to the Bureau of Vital Records to register such birth and issue a certificate of birth. The Petitioner, subject to penalty of perjury, states that the information contained in this petition is true and correct to the best of the petitioner’s knowledge. Date OSCA (10-05) CV310 Petitioner’s Signature 1 of 1 193.105, 193.115 RSMo American LegalNet, Inc. www.USCourtForms.com