Birth Certificate Application

Birthplace

Please enter the location of the birth for the person on record.

State of birth

County of birth

City or Town of birth

Borough of Birth

Island of Birth

Place of Birth (City or County)

Hospital of birth

Name of Attendant at Birth

If child is less than age 2, list the name of the Hospital or the Midwife

Birth information for the person on record

Please enter the birth information of the individual who needs the birth certificate. If you are applying for someone else (i.e. your child), enter their birth information here.

First Name

Middle Name

Last Name

Full Name at Birth

Suffix at Birth

Sex

Male Female

Race

Could this birth be recorded under any other name?

Yes No

Other Name

Was this child adopted?

Yes No

Is the request for record before adoption?

Yes No

First Name Before Adoption

Last Name Before Adoption

Name after Adoption

Original name of subject if different at birth

Have there been any corrections or changes to the information on this certificate?

Yes No

Has the subjects name changed since birth due to marriage?

Yes No

State of Marriage

Date of Marriage

Has your name changed since birth through a court order (for reasons other than marriage)?

Yes No

Changed name

Changed Name

Has any legal action changed the information on the birth record?

List Previous Name on Birth Certificate

Has the subject's name changed since birth?

Yes No

Subject's Original Name

Changed First Name

Changed Middle Name

Changed Last Name

Changed Name

Describe Change

Changed Suffix

Date of Birth

Age at last birthday

Order of this Birth

Is the person on record still living?

Yes No

Is the person on record deceased?

Yes No

State of Death

Year of Death

Date of death

Decedent's name at time of death

Next older brother or sister

Next younger brother or sister

Does this subject belong to an Arizona Tribe?

Yes No

Specify Tribe

Parents

Please enter the information of the parents of the subject of the birth certificate.

How should the parents be listed on the birth certificate?

Mother/Father Parent/Parent

Mother/Parent A First Name

Mother/Parent A Middle Name

Mother/Parent A Maiden Name

Full name on Birth Certificate

Mother/Parent A Current Last Name

Full maiden name of the Mother/Parent A (prior to first marriage)

Mother/Parent A Name (First, Middle, Last prior to first marriage, current legal name)

Full name of Mother

Mother's Suffix

Mother's last name at the time of this birth

Mother/Parent A Date of Birth

Mother/Parent A City of Birth

Mother/Parent A State/Country of Birth

Adopted Mother's Birth Name

Number of children born in South Carolina to this mother/parent

Was the mother married at the time of conception or birth?

Yes No Unknown

Is the Father unknown or not listed on the birth certificate?

Yes No

Father/Parent B First Name

Father/Parent B Middle Name

Father/Parent B Current Last Name

Full name of the Father/Parent B

Father/Parent B Name (First, Middle, Last prior to first marriage, current legal name)

Father/Parent B Maiden Name

Father/Parent B's Suffix

Father/Parent B Date of Birth

Father/Parent B City of Birth

Father/Parent B State/Country of Birth

Adopted Father's Birth Name

Were the parents married at the time of the subject's birth?

Yes No

Customer Information

Provide your information, including your name, phone number, email address, and your reletion to the subject of the birth record.

Customer First Name

Customer Middle Name

Customer Last Name

Customer Suffix

Customer Full Name

Work Phone Number

Phone Area Code

Phone Number

Phone number (first 3 digits)

Phone number (last 4 digits)

Alternate Phone Area Code

Alternate Phone Number (optional)

Email address

Email Address (first part)

Email Address (@__________)

Birthdate of Customer

Physical Street Address

Apartment #

City

State

ZIP code

Gender

Male Female

Type of Valid ID

State where Identification was Issued

Identification Number

ID Expiration Date

Your relation to the person on record

Relation to person of record

Type of Record you're requesting

Public Confidential

Relation to person of record

Relation to person on record

Who are you the legal representative for?

Describe your personal/property interest

Specify Type of Authorized Agent

Relationship to Decedent

Certificate Request

Please provide the reason why the birth certificate is being requested, along with other required details regarding the certificate request.

Birth Certificate Number (If Known)

State file number (If Known)

Local Registration Number (If Known)

Include copy of acknowledgment of paternity with birth certificate?

Do you need a letter of exemplification?

Yes No

Is this certificate for an Apostille?

Yes No

Foreign born certificate?

Yes No

Was there a delay in filing the birth certificate?

When was the birth certificate filed?

Reason for Request

Date of Request

Mailing Address

Please enter the address where you would like the birth certificate to be delivered.

Street Address

Apt, Suite, Floor, Etc.

City

State

City, State

ZIP code

City, State ZIP

Mailing Address of Customer

Physical Address of Applicant

Delivery Preference

Regular Mail Express Courier

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Birthplace

Birth information for the person on record

Parents

Customer Information

Certificate Request

Mailing Address

FAQs