Texas Certificate Birth Form PDF Details

When you are born, the hospital typically files a birth certificate with the state. This document lists your full name, date of birth, and place of birth. In order to get a copy of your Texas Certificate Birth Form, you will need to submit a request to the appropriate government agency. There are different ways to do this, so be sure to follow the instructions carefully. Failure to do so may result in delays or even refusal of your request. For more information, please visit our website today.

You will see information about the type of form you would like to submit in the table. It can show you the time it may need to finish texas certificate birth form, exactly what fields you will need to fill in, and so forth.

QuestionAnswer
Form NameTexas Certificate Birth Form
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
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Form Preview Example

 

OFFICE USE ONLY

☐ CHECK ☐ MONEY ORDER

 

REMITTANCE NO. ______________CERT. #_______________________

Texas Department of State

DATE ______________________

AMOUNT $_____________________

Health Services

DOCUMENT CONTROL # ______________________________________

MAIL APPLICATION FOR BIRTH RECORD

__________________________________________________________

PLEASE PRINT CLEARLY.

INCLUDE A COPY OF YOUR (APPLICANT) VALID ID WHEN SENDING IN THE REQUEST. APPLICATION MUST BE ORIGINAL (INCLUDING SIGNATURE). NO CROSS OUT OR WHITE OUT WILL BE ACCEPTED. SEE INSTRUCTIONS ON BACK.

Step 1: YOUR INFORMATON AND SHIPPING ADDRESS (PLEASE PRINT)

Your Name (First, Middle, Last Name):

Street Address:

City:

 

State:

 

Zip Code:

 

 

 

 

 

 

Email Address:

 

 

Daytime

 

 

 

 

 

Phone Number:

Your relationship to Person named on Certificate (Check One):

☐ Self ☐ Child

☐ Spouse

☐ Parent ☐ Sibling

☐ Grandparent ☐ Legal Guardian (proof required) ☐ Legal Representative (proof required) ☐ Other:_______________________

☐ I authorize mailing to the address below instead of my mailing address listed above.

Name:

Address to Send to if different than noted above:

 

City:

 

State:

Zip Code:

 

 

 

 

 

 

Reason for Request:

 

 

 

 

 

☐ Newborn ☐ Travel/Passport ☐ Records

☐ School ☐ Insurance

☐ Other: _______________________________

Step 2: INFORMATION FOR PERSON NAMED ON BIRTH RECORD (Must be completed to Identify Record Requested)

 

 

FULL NAME

 

First Name

 

 

 

 

Middle Name

 

 

Last Name

 

 

ON RECORD:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF

 

Month

Day

 

Year

 

 

 

SEX:

 

 

BIRTH:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLACE OF

 

City or Town

 

 

 

 

County

 

 

TEXAS ONLY

 

 

BIRTH:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FULL NAME OF

 

First Name

 

 

 

 

Middle Name

 

 

Maiden Last Name (Before first marriage)

 

 

PARENT 1:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FULL NAME OF

 

First Name

 

 

 

 

Middle Name

 

 

Maiden Last Name (Before first marriage)

 

 

PARENT 2:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Step 3: COST &

FEES (NOT REFUNDABLE, if Record Not

found)

| Step 4: AFFIDAVIT (NOTARY SECTION)

 

 

Select Record Type:

 

Qty

 

Price/each

 

 

 

Total

 

ONLY applications for birth certificates (NOT birth

 

 

☐ Long Form Birth Certificate

 

 

 

x $22.00

 

$

 

verifications) submitted by mail need to be notarized

 

 

 

 

 

 

 

 

 

 

 

(Travel/Passport)

 

 

 

 

 

 

 

 

 

 

 

STATE OF _________________________

 

 

☐ Short Form Birth Certificate (General Use)

 

 

x $22.00

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

☐ Texas Flag Heirloom Birth Certificate

 

 

 

x $60.00

 

$

 

COUNTY OF________________________

 

 

(Framing and Display)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

☐ Bassinet Heirloom Birth Certificate

 

 

 

x $60.00

 

$

 

This instrument was acknowledged before me

 

 

(Framing and Display)

 

 

 

 

 

 

 

 

 

 

on________________

 

 

☐ Birth Verification (Letter, not official

 

 

 

x $22.00

 

$

 

 

 

certificate)

 

 

 

 

 

 

 

 

 

 

 

(Date)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

☐ Military Personnel with current

 

 

 

 

Exempt

 

By________________________________________

 

 

deployment orders

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Printed Name of applicant acknowledging)

 

 

☐ Foster or Homeless child or youth

 

 

 

 

Exempt

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For urgent requests, orders may be EXPEDITED by sending the order through an

 

 

 

 

 

overnight mail service, such as: FEDEX, LoneStar, or UPS to our physical address:

 

_______________________________

 

 

DSHS – VSS MC 2096, 1100 W. 49th St., Austin, TX 78756 and paying the

 

(Notary Public’s Signature)

 

 

below expedited processing fee.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

☐ Expedited Processing (estimated 20-25 business days)

 

 

 

 

 

$5.00

 

 

 

 

 

All orders are returned free of charge by USPS regular mail. For expedited return

 

 

(Personalized Seal)

 

 

mail service, select one of the overnight return shipping methods below.

 

 

 

 

 

☐ Overnight Return Mail (for shipping within USA)

 

 

 

 

 

$8.00

 

 

 

 

 

☐ USPS Express Return Mail (for shipping to PO Box ONLY)

 

 

$22.95

 

 

 

 

 

☐ I wish to make a voluntary contribution of $5.00 to promote healthy

 

 

$5.00

 

WARNING: IT IS A FELONY TO FALSIFY INFORMATION ON THIS

 

 

early childhood by supporting the Texas Home Visitation Program

 

 

 

 

 

 

 

 

 

 

DOCUMENT. THE PENALTY FOR KNOWINGLY MAKING A FALSE

 

administered by the Office of Early Childhood Coordination of Health and

 

 

 

 

 

 

 

 

 

STATEMENT ON THIS FORM OR SIGNING A FORM WHICH

 

 

Human Services.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTAINS A FALSE STATEMENT IS 2 TO 10 YEARS IMPRISONMENT

 

 

 

 

 

 

 

 

Total

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

AND A FINE OF UP TO $10.000. (HEALTH AND SAFETY CODE,

 

 

 

 

 

 

 

 

Due:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHAPTER 195, SEC. 195.003.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

READ & SIGN (Applications without signatures or attached valid ID will NOT be accepted for processing)

Signature of Applicant __________________________ Date Signed (MM/DD/YYYY) _____/_____/_________

VS – 140 (1/21)

TEXAS

Health and Human

Texas Department of State

Services

Health Services

MAIL APPLICATION FOR BIRTH RECORD

Processing times are estimates and subject to change with an increased volume of customer applications.

FAILURE TO PROVIDE INFORMATION REQUESTED ON THIS FORM MAY RESULT IN SIGNIFICANT PROCESSING DELAYS AND/OR DENIAL OF YOUR APPLICATION.

Walk In: Same day service in most cases. Hours are Monday-Friday 8:00 am - 4:00 pm. DSHS - Vital Statistics Section, 1100 W. 49th St., Austin, TX 78756

Online Orders: Visit www.texas.gov to order online. Online orders are mailed 15-20 business days after receipt of the request.

Mail In Orders: Processed and mailed 6 - 8 weeks after receipt of the request. Mail to: DSHS - VSS, P.O. Box 12040, Austin, TX

78711-2040. For current processing times, please see our website at: https://www.dshs.texas.gov/vs/processing/.

Expedited Orders: Processed and mailed 20 - 25 business days after receipt of the request. Must be sent to the Texas Department

of State Health Services - Vital Statistics Section via an OVERNIGHT mail service, such as FedEX, LoneStar, or UPS to: DSHS – VSS

MC 2096, 1100 W. 49th St., Austin, TX 78756

Long form Birth Certificate - Most comprehensive birth record. It is a copy of the original birth certificate. It will also show a history of corrections that have been made to the birth record. This form is often used for requesting passports.

Short form Birth Certificate - An abstract of the birth record. This birth certificate will only show current information for the child's name, date of birth, place of birth, sex, and name of parent(s). This form will not show a history of corrections. This form is often

used for school records and is acceptable for most purposes.

Heirloom birth certificate - Heirloom birth certificates are abstracts of the birth record. They are primarily used for framing and display. The information on an "heirloom birth certificate" is similar to a "short form". Examples of heirloom birth certificates can be seen on our website at http://www.dshs.texas.gov/reqproc/heirloom.shtm.

Verification Letter - A verification letter will include the child’s name, the date of birth, and the county where the birth occurred. Verification letters are available for births that have occurred since 1903. Verification letters are not considered legal substitutes for certified copies of birth certificates. The VSS strongly recommends that applicants ensure a verification will satisfy its intended use.

Military Personnel with current deployment orders – Texas Government Code 437.217. EXEMPTION FROM FEES FOR MILITARY PERSONNEL. A member of the National Guard on federal active duty, or a member of the armed forces of the United States on active duty, who is preparing to be deployed to serve in a hostile fire zone as designated by the United States secretary of defense is exempt from paying the following state or local governmental fees the member incurs because of the deployment to arrange the member's personal affairs: (1) fees for obtaining copies of: (A) a birth certificate. MILITARY ID AND MILITARY ORDERS ARE REQUIRED.

Foster or Homeless child or youth – Texas Health and Safety Code 191.0049. BIRTH RECORD ISSUED TO FOSTER CHILD OR YOUTH OR HOMELESS CHILD OR YOUTH. On request of a child or youth described by this section, the state registrar, a local registrar, or a county clerk shall issue, without fee or parental consent, a certified copy of the child's or youth's birth record to:

(1)a homeless child or youth as defined by 42 U.S.C. Section 11434a; (2) a child in the managing conservatorship of the Department of Family and Protective Services; and (3) a young adult who: (A) is at least 18 years of age, but younger than 21 years of age; and (B) resides in a foster care placement, the cost of which is paid by the Department of Family and Protective Services. DOCUMENTATION OF STATUS IS REQUIRED.

Copies of birth certificates for births that occurred within the past 75 years can be requested only by the immediate family of the person whose name is on the birth certificate. See Section 181.1(13) of the Texas Administrative Code for who qualifies as an immediate family member. An immediate family member is the child, their guardian, their children, spouses, parents, siblings, or grandparents.

Applicants who are not immediate family members must provide legal documentation (such as a court order establishing guardianship) that demonstrates a direct, tangible interest in the birth certificate.

The applicant must include a copy of his or her valid photo ID issued by a governmental entity. See Section 181.28 of the

Texas Administrative Code for a complete list of acceptable forms of identification. You also can see VSS’s page on acceptable identification in English (http://www.dshs.texas.gov/vs/reqproc/Acceptable-IDs/) and Spanish (http:// www.dshs.texas.gov/vs/reqproc/Acceptable-IDs-(Spanish)/).

If a record is not on file, our office will issue a “not found” letter.

Customer Checklist

☐Complete steps 1, 2, and 3 of the application. Please type or print clearly.

☐Complete step 4 of the application and have it notarized, if requesting a birth certificate.

☐Sign and date the application.

☐Make sure the application is original and not a photocopy and there are no cross-outs or white-out.

☐Enclose a copy of a current driver's license, passport or state identification. See complete ID list on our website.

☐Enclose appropriate fees. Make checks or money orders payable to DSHS – Vital Statistics.

For more information, go to: https://www.dshs.texas.gov/vs/requirements.aspx.

For the status of your request, contact VSS by telephone at 1-888-963-7111 or online at: https://www.dshs.texas.gov/orderstatus/.

VS – 140 (1/21)

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