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Petition for Establishing Record of Birth Form. This is a Missouri form and can be use in Circuit Court Statewide.
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Tags: Petition for Establishing Record of Birth, CV310, Missouri Statewide, Circuit Court
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
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