Form Dh 1960 – Fill Out and Use This PDF

APPLICATION FOR A FLORIDA BIRTH RECORD

Department of Health in Manatee County - Vital Statistics

410 6th Avenue East	Office Hours: 7:30 am - 4:00 pm
Bradenton, Florida 34208	Monday thru Friday
(941) 748-0747 Option # 5	Fax (941) 714-7282

Read the FRONT AND BACK of this application: Requirement for ordering: If applicant is self, parent, guardian, or legal representative, then the applicant must complete this application and provide valid photo identification, if a mail request, a copy of the valid photo identification must be provided. If applicant is not one of the above, the Affidavit to Release a Birth Certificate must be completed by an authorized person and submitted in addition to this application form. Acceptable forms of identification are the following: Driver’s License, State Identification Card, Passport, and/or Military Identification Card.

SECTION A: REGISTRANT INFORMATION

FULL NAME AS SHOWN ON		FIRST		MIDDLE			LAST	SUFFIX
BIRTH RECORD
IF NAME WAS CHANGED SINCE		FIRST		MIDDLE			LAST	SUFFIX
BIRTH, OTHER THAN MARRIAGE
	MONTH		DAY	YEAR (4 DIGIT)		STATE FILE NUMBER (If known)		SEX
DATE OF BIRTH
		HOSPITAL		CITY OR TOWN			COUNTY
PLACE OF BIRTH
		FIRST		MIDDLE		LAST NAME PRIOR TO FIRST MARRIAGE		SUFFIX
MOTHER’S / PARENT’S NAME							(If applicable)
		FIRST		MIDDLE		LAST NAME PRIOR TO FIRST MARRIAGE		SUFFIX
FATHER'S / PARENT’S NAME							(If applicable)

IMPORTANT INFORMATION

Any person who willfully and knowingly provides any false information on a certificate, record or report required by Chapter 382, Florida Statutes, or on any application or affidavit, or who obtains confidential information from any Vital Record under false or fraudulent purposes, commits a felony of the third degree, punishable as provided in Chapter 775, Florida Statutes.

SECTION B: APPLICANT (adult requesting certificate) INFORMATION

HOME PHONE NUMBER

MAILING ADDRESS (INCLUDE APT. NO., IF APPLICABLE)

RELATIONSHIP TO REGISTRANT

(	)
	ALTERNATE PHONE NUMBER	CITY	STATE	ZIP CODE

()

LICENSE/ BAR NUMBER

NAME OF PERSON REPRESENTED and THEIR RELATIONSHIP TO REGISTRANT

IF ATTORNEY, PROVIDE BAR/PROFESSIONAL LICENSE NO.

CERTIFICATES AND FEES-Certificates available for FLORIDA BIRTHS ONLY

Method of Payment: Visa, Master Card or Money Order Only					We do not accept personal checks
CREDIT CARD INFORMATION: Must provide if faxing application
	Visa		MasterCard	Credit Card Number:		Expiration Date:
County Vital Statistics Office Use Only
Date ____________________		Safety Paper Number ___________________________________________ Employee Initials ____________

DH 1960, 04/2016, Florida Administrative Code Rule 64V-1.0131 (Obsoletes Previous Editions)

INFORMATION AND INSTRUCTIONS FOR BIRTH RECORD APPLICATION

COMPUTER CERTIFICATION: computer certifications are accepted by all state and federal agencies and used for any type of travel.

A computer certification has two different formats:

1.A certification of a registered birth (2004 to present), supplies the following facts of birth: Child's Name, Date of Birth, Sex, Time, Weight, Place of Birth (City, County and Location) and Parents' Information.

2.A certification of a registered birth (1930 to 2003), supplies the following facts of birth: Child's Name, Date of Birth, Sex, County of Birth and Parents' Name.

AVAILABILITY: Birth registration was not required by state law until 1917, but there are some records on file dating back to 1865.

ELIGIBILITY: Birth certificates can be issued only to:

1.Registrant (the child named on the record) if of legal age (18)

2.Parent(s) listed on the Birth Record

3.Legal guardian (must provide guardianship papers)

4.Legal representative of one of the above persons

5.Other person(s) by court order (must provide recorded or certified copy of court order)

In the case of a deceased registrant, upon receipt of the death certificate of the decedent, a certification of the birth certificate can be issued to the spouse, child, grandchild, sibling, if of legal age, or to the legal representative of any of these persons as well as to the parent.

Any person of legal age may be issued a certified copy of a birth record (except for those birth records under seal) for a birth event that occurred over 100 years ago.

BIRTH RECORDS UNDER SEAL: Birth records under seal by reason of adoption, paternity determination or court order cannot be ordered in the usual manner. For a record under seal, write to:

BUREAU OF VITAL STATISTICS

ATTN: Records Amendment Section

P.O. BOX 210

Jacksonville, FL 32231-0042

REQUIREMENT FOR ORDERING: If applicant is self, parent, legal guardian or legal representative, the applicant must provide a completed application along with valid photo identification, if a mail request, a copy of the valid photo identification must be provided. If legal guardian, a copy of the appointment orders must be included with the request. If legal representative, the attorney bar number, and a notation of whom the attorney represents and that person's relationship to the registrant must be included with your request. 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. Acceptable forms of identification are the following: Driver’s License, State Identification Card, Passport and/or Military Identification Card.

If not one of the above, you must complete this application and have a notarized Affidavit to Release A Birth Certificate (DH Form 1958, 08/2010) submitted with your application for the birth record along with a copy of the registrant's valid photo identification as well as the applicant's valid photo identification.

RELATIONSHIP TO REGISTRANT: A person ordering his or her own certificate should enter "SELF" in this space. Also, explain if name has been changed; married name, name changed legally (when and where), etc. Others must identify themselves clearly as eligible (see ELIGIBILITY above).

NONREFUNDABLE: Vital record fees are nonrefundable.

APPLICANT’S SIGNATURE: Is required, as well as his/her printed name, residence address and telephone number.

COUNTY HEALTH DEPARTMENT NAME AND ADDRESS

OPTIONS FOR RUSH SERVICE:

FAXED REQUESTS: Fax number is (941) 714-7282. Requests are processed within 2 working days upon receipt of the completed application

and mailed the following business day. Payment must be made with Visa or MasterCard. The credit card must be in the applicant's name with same billing address. A copy of the applicant's valid photo ID (front & back) must accompany this completed application.

Please enlarge your ID to 150 % and lighten.

EXPRESS MAIL SERVICE: An additional $15.00 fee for mailing certificates VIA Federal Express Service.

WE HAVE NO WEEKEND DELIVERY

Method of Payment: Visa, Master Card or Money Order Only We do not accept personal checks

Money orders should be made payable to : Manatee County Vital Statistics 410 6th Avenue East Bradenton, Florida 34208

visit our local office at manatee.floridahealth.gov

PLEASE VISIT THE BUREAU OF VITAL STATISTICS WEBSITE

http://www.floridavitalstatisticsonline.com

DH 1960, 04/2016, Florida Administrative Code Rule 64V-1.0131 (Obsoletes Previous Editions)