BIRTH CERTIFICATES TEXAS ONLY $23 PER COPY/ # OF COPIES (# DE COPIAS) *Cash only if submitting request in person *If submitting request through the mail please send Money Order Only DRIVERS LICENSE OR ID FROM THE DEPARTMENT OF MOTOR VEHICLES IS THE ONLY TYPE OF IDENTIFICATION THAT IS ACCEPTED. WHEN ORDERING BY MAIL, PLEASE INCLUDE A COPY OF IDENTIFICATION. A NON-REFUNDABLE SEARCH FEE OF $23 WILL APPLY FOR ALL SEARCHES AND/OR CERTIFIED COPIES NAME ON BIRTH RECORD (NOMBRE EN LA ACTA DE NACIMIENTO) FIRST NAME/ PRIMER NOMBRE DATE OF BIRTH: FECHA DE NACIMIENTO: MID. NAME/ SEGUNDO NOMBRE MONTH/ MES DAY / DIA LAST NAME/ APELLIDO SEX: MALE YEAR. / AÑO FEMALE (MASCULINO) (FEMENINA) COUNTY OF BIRTH (CONDADO DE NACIMIENTO): NAME OF HOSPITAL CHILD WAS BORN: _____________________________________________________ FATHER’S NAME: NOMBRE DEL PADRE: FIRST NAME/ PRIMER NOMBRE MID. NAME/ SEGUNDO NOMBRE LAST NAME/ APELLIDO MID. NAME/ SEGUNDO NOMBRE LAST NAME/ APELLIDO MOTHER’S NAME: NOMBRE DE MADRE: FIRST NAME/ PRIMER NOMBRE MOTHERS MAIDEN NAME/ APELLIDO DE SOLTERA: PLEASE CHECK ONE (ELIGA UNO): LONG FORM / FORMA LARGA ________AMENDED CERTIFICATE______ABSTRACT / FORMA CORTA __ LONG FORM BIRTH CERTIFICATES ARE MORE DETAILED AND MAY BE A REQUIRMENT WHEN OBTAINING A PASSPORT, PLEASE CHECK WITH YOUR PASSPORT OFFICE BEFORE MAKING YOUR PURCHASE. THERE WILL BE NO REFUNDS OR EXCHANGES ONCE YOU LEAVE THE OFFICE. THIS OFFICE PROVIDES “LONG FORMS” FOR SUBSTATIONS OUTSIDE OF THE DALLAS CITY LIMITS ONLY! EX. APPLICANT’S INFORMATION / INFORMACION DEL APPLICANTE NAME (NOMBRE): DRIVER’S LICENSE # OR ID # NUMERO DE LICENSIA O ID: SOCIAL SECURITY NO. NO. DE SEGURO SOCIAL: - - DAYTIME PHONE NO. NO. DE TELEFONO: ( ) - MAILING ADDRESS (DOMICILIO) / STREET APT# / CITY/ CIUDAD / STATE / ESTADO ZIP RELATIONSHIP TO PERSON ON RECORD / RELACION A LA PERSONA EN LA ACTA? PURPOSE FOR ABTAINING RECORD / RAZON PARA OBTENER LA ACTA? SIGNATURE OF APPLICANT FIRMA DEL APLICANTE: DATE FECHA: / / OFFICE USE ONLY ISSUING CLERK ________________SECURITY NO. _____________________ RECEIPT NO. __________________ HOSPITALS IN: GARLAND, MESQUITE, RICHARDSON, IRVING, LANCASTER, CARROLLTON AND LAS COLINAS American LegalNet, Inc. www.FormsWorkFlow.com