Form 522 Mississippi PDF Details

Navigating through personal administrative tasks can often feel overwhelming, especially when it involves obtaining crucial documents such as birth certificates. The 522 Mississippi form serves as an application for those in need of a certified Mississippi birth certificate, catering to a wide array of citizens from parents to legal representatives. Managed by the Mississippi State Department of Health Vital Records, this form simplifies the process of applying for a birth record by outlining specific requirements for eligibility, necessary identification, fees, and the rightful claimants entitled to access this sensitive information. Not only does it address individuals directly seeking their own records or those of immediate family members, but it also extends its services to legal guardians, licensed adoption agencies, and those requiring access by court order, thereby ensuring that the application process is inclusive. Applicants are guided through a straightforward process of submitting their application with an advance payment of a non-refundable search fee alongside valid photo identification. With detailed instructions provided regarding acceptable forms of identification, additional copy fees, and the non-returnable nature of the fee even when records are not found, this form streamlines the journey towards acquiring a birth certificate. A distinguishing feature of the 522 form is its commitment to cater to various needs, including genealogy research, further emphasizing the importance of access to vital records in affirming one's identity and lineage.

QuestionAnswer
Form NameForm 522 Mississippi
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesAnnotated, msdh, Registrant, phs

Form Preview Example

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.

The $15.00 fee entitles the applicant to one Certified copy of the birth record on file of if the record is not found a “Not on File” statement will be issued. Surrounding counties and five years centered on year of birth are searched if record is not located within county or year specified.

$ 15.00

X

1

=

$15.00

Additional Certified copies of the same record ordered at the same. $5.00 for each additional certified copy.

TOTAL AMOUNT ENCLOSED. Check or Money Order payable to Mississippi Vital Records. Mississippi law allows an additional Service charge for dishonored checks. (DO NOT SEND CASH)

$ 5.00

X

 

=

 

 

 

 

 

 

 

 

 

 

Amt.

 

 

No. of copies

 

Enclosed

TOTALS

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