VALID IDENTIFICATION WITH APPLICANT'S SIGNATURE MUST BE SHOWN

BIRTH RECORDS ARE AVAILABLE TO THE INDIVIDUAL OR A MEMBER OF HIS(HER) IMMEDIATE FAMILY ONLY

	Full Name at Birth   Name after adoption or court order   Date of Birth   City of Birth   Full Name of Father   Full MAIDEN Name of Mother   Your relationship to individual record requested   Number of certificates requested($6.00 per)   Signature of Applicant   Address   Phone

FALSE APPLICATION, ALTERING, MUTILATING, OR COUNTERFEITING INDIANA BIRTH CERTIFICATES IS A CRIMINAL OFFENSE - INDIANA LAW IC-16-1-19-6

OFFICE USE ONLY

ID SHOWN___________________________BY________________________

Directions:

(1) When mailing request, please enclose a self-addressed, stamped envelope.
(2) Check or Money Order made to Madison County Health Dept.
(3) Mail to Madison County Health Department above.