Certificado De Nacimiento Washington

Birth Certificate Request*
Vital Records Division
For District of Columbia Occurrences Only
RESTRICTION: Family or legal representatives only. See page two for details
Mail-In Form
1.Certificate Holder's Name:

(See below for Instructions)
(First)

2. Birth Date:

(Middle)

/

3. Sex:

Male

/

(Last)
(mm/dd/yyyy)

Female

4. Hospital:
5. City:
6. Father's Name:Washington, DC
(First)

(Middle)

(Last)

7. Mother's Maiden Name:
(First) (Middle) (Maiden)
8a. Number of Original Certificate Forms Requested:
$23.00 each
8b. Total Amount Enclosed:* *
9.Relationship to Certificate Holder:

Total Cost: $
$
Self

Mother

Father

Other

10. Signature of Requester:

_____________________________________

11. Date:
Mail Certificate(s)to:
12. Name:

_________/_________/_________ (mm/dd/yy)

13. Address:
14. City/State/Zip Code::
15. Day Phone: (Required)
* Copy of Requester's Photo ID Required.
If record is not located a"Certificate of Search" will be issued.
**Beginning January 1, 2009, all mail-in requests must include a stamped self addressed No. 10 (4 1/8" x
9 1/2") business size return envelope.
**The DCTreasurer requires that all checks have an address imprinted on them to be accepted for
deposit. Starter checks are not accepted.

Instructions to be completed:
1. Print, sign, enclose requestor's photoID and date the form
2. Enclose check or money order payable to DC Treasurer
3. Mail to: Department of Health
Vital Records Division
899 North Capitol Street, NE, 1st Floor
Washington, DC 20002(202) 442-9303

Birth Application Instructions
The birth certificate request form contains 12 questions. A separate copy of the request form should be
completed for each person whose birth recordis being requested. However, multiple copies of a single birth
record may be requested on the same form.
Items 1-7: Personal information about the certificate holder.
Item 8a: Please indicate...