Form 522 Mississippi – Fill Out and Use This PDF

APPLICATION FOR CERTIFIED MISSISSIPPI BIRTH CERTIFICATE

Mississippi State Department of Health

Vital Records

Post Office Box 1700, Jackson, Mississippi 39215-1700

FULL NAME ON

FIRST

MIDDLE

LAST

BIRTH RECORD

HAS NAME CHANGED

If so, what was original name?

SINCE BIRTH?

□ Yes

□

No

DATE OF

MONTH

DAY

YEAR

STATE FILE NUMBER IF KNOWN

BIRTH

PLACE OF

COUNTY

CITY

STATE

BIRTH

SEX

RACE

□

MALE

□ FEMALE

FULL MAIDEN

FIRST

MIDDLE

LAST

NAME OF MOTHER

FULL NAME

FIRST

MIDDLE

LAST

OF FATHER

PERSON REQUESTING CERTIFIED COPY

RELATIONSHIP TO APPLICANT

PURPOSE FOR WHICH NEEDED

SIGNATURE OF APPLICANT

DATE

A BIRTH RECORD SEARCH REQUIRES ADVANCE PAYMENT OF A NON REFUNDABLE SEARCH FEE OF $15.00 AND VALID PHOTO IDENTIFICATION.

PHOTO IDENTIFICATION REQUIRED

Failure to provide the proper identification will result in the application being returned to you without processing. Acceptable forms of identification are: Valid Driver’s License, State Issued Identification Card, Passport, and/or Military Identification Card, Valid School, College or University Identifications. (See back for other acceptable forms).

APPLICANT NAME/DELIVERY INFORMATION

Pursuant to Section 41-57-2 of the Mississippi Code of 1972, Annotated and as defined by Mississippi State Board of Health Rules and Regulations only person having legitimate and tangible interest in a birth certificate is entitled to obtain a copy. Anyone obtaining a copy of a birth certificate under false pretenses is subject to the penalties as described in Section 41-57-27 of the Mississippi Code.

PRINT YOUR MAILING ADDRESS HERE

Applicant Name (Type or Print)

Delivery Address (include apt number)

City			State		ZIP Code		Phone Number, including area code
			DO NOT WRITE IN THE SPACES BELOW – FOR OFFICE USE ONLY
	12	–36		S.C.		SUP.
	37	– 66		S.C.		P.
	S.C.			C.D.		CWA.

Mississippi State Department of Health

Revised 3-18-11

Form 522

INFORMATION AND INSTRUCTIONS FOR BIRTH RECORD APPLICATION

Eligibility:	A certified copy of a birth certificate can be issued only to a person with legitimate and tangible
	interest as defined by the Rules Governing the Registration and Certification of Vital Events.
	Primarily this is:
	1)	Registrant (the child named on the record), if of legal age.
	2)	Parent(s) listed on the birth record, if VR office has not been notified of termination of parental rights.
	3)	Spouse, sibling(s), or grandparent(s)/child(ren) of registrant, proof of relationship required.
	4)	Legal Guardian, guardianship papers must be provided.
	5)	Legal representative of one of the above persons, proof of representation must be provided.
	6)	Licensed adoption agencies working within the statutory authority of §93-17-205.
	7)	Other person(s) by court order, certified copy of court order must be provided.

Birth records are available for genealogy purposes for birth events occurring over 100 years ago. Genealogy must be provided as purpose for certificate and family relationship to the registrant must be specified. Plain paper copies rather than certified copies are provided for genealogy purposes.

Requirements for Ordering: If applicant is self, spouse, parent, grandparent, sibling, child, grandchild, guardian, or legal representative, then the applicant must provide a completed application and a copy of a valid photo identification of the applicant. Acceptable forms of identification are the following:

■ Photo Driver’s License	■ Photo State Issued ID	■ Employment ID
■ School, College or University ID	■ US Military ID	■ Tribal ID
■ Alien Registration/Permanent Resident Card	■ Temporary Resident Card	■ US Passport

OR two forms of identification from the following list:

■ Social Security Card	■ Utility Bill (showing address)	■ Medicaid Card
■ Snap/EBT card (showing address)	■ Work Identification	■ Veteran Universal Access ID Card

Guardian or legal representative must submit proof of guardianship/legal representation with this application. Legal representatives must provide attorney bar number, name of person represented, and their relationship to the registrant. If you are an agent of local, state or federal agency requesting a record, indicate in the space provided for “relationship” the name of the agency. If you do not have one of the above referenced documents, please contact Vital Records at 601-576-7981.

Relationship to Applicant: A person ordering his or her own certificate should enter “SELF” in this space. Also, explain if name has been changed by marriage, legal name change (when and where), etc. Others must identify their relationship to the registrant clearly.

Nonrefundable: Vital record fees are nonrefundable, with the exception of fees paid for additional copies when no record is found.

Failure to Receive: Complaints of failure to receive certified records will be honored within 6 months of the original request. If the copy was to be returned to you by U.S. Postal Service, please allow 3 weeks after mailing the request before inquiring. Inquiry about copies ordered with payment for special courier delivery should be made within 7 days of the request. Mail returned because of insufficient address or address changes will be re-mailed if this office is notified of correct address within 6 months of request.

Options for Service: Certified copies of birth records may be ordered in person, by mail, or, if paying by credit card, online or by telephone. Processing time is generally 7 – 10 working days after receipt of request. If amendment action is necessary, additional processing time will be required. Payment of fees is required at the time of ordering.

•WALK-IN SERVICE is available at 571 Stadium Drive, Jackson, Mississippi between the hours of 8:00 am and 5:00 pm. Most records will be available while you wait, some require special processing and will be mailed within 7 - 10 days of the request.

•MAIL-IN requests, either on the form provided or as a free form request will be processed in the order received and will be returned by regular U.S. Postal Service, unless accompanied by a prepaid special courier self-addressed envelope.

•PAYMENT BY CREDIT CARD can be done using an online service or by telephone. The private company approved to handle credit card transactions for Mississippi birth records can be accessed by calling 601-576-7988 or by visiting www.msdh.state.ms.us/phs and clicking on link for online ordering. If you have questions or need additional assistance call 601-576-7981. A recorded message outlining ordering requirements and options can be accessed by dialing 601-576-7450.

MAIL THIS APPLICATION WITH PAYMENT AND COPY OF IDENTIFICATION TO:

MISSISSIPPI VITAL RECORDS

P.O. BOX 1700

JACKSON, MS 39215-1700

Mississippi State Department of Health

Revised 3-18-11

Form 522