REQUEST FOR CERTIFIED COPY OF A BIRTH RECORD
DEPARTMENT OF HEALTH AND HUMAN SERVICES
VITAL RECORDS UNIT
SFN 8140 (1-2024)
PLEASE PRINT - ALL ITEMS MUST BE COMPLETED AND LEGIBLE TO LOCATE AND IDENTIFY THE RECORD
1. Full Name on Birth Record (If adopted, list adoptive name)
2. Sex
Male Female
4. Place of Birth (City, Township or County)
3. Date of Birth (Month, Day, Year)
5. Full Name of Father (First, Middle, Last) (If adopted, list adoptive father/parent name)
6. Full Name of Mother (First, Middle, Maiden) (If adopted, list adoptive mother/parent name)
7. Number of Certified Copies Requested ($15.00 per copy requested)
Certified (For all official purposes, including U.S. Passport, Driver’s License, etc.)
Genealogy (For researching family history - not available for births occurring after 2005)
8. Fees: (Check or Money Order)
$ .00
9. Requestor Relationship to Person on Line 1*
Self (must be 16 or older) Mother/Father Public (Only if record is over 125 years old) Authorized Rep (include court order)
Legal Guardian (must include guardianship papers - Social Services must also include employment photo ID)
* If individual on line #1 is deceased, you must include a certified death certificate (which will be returned) and indicate your relationship.
spouse, parent, child, grandparent, or grandchild
Requestor MUST COMPLETE and SIGN and include their name, address and telephone number.
Requestor Signature
Date Signed
Requestor Printed Name
Daytime Telephone Number
( )
Mailing Address (please include your Apartment Number, if applicable) Apartment Number
City
State
ZIP Code
Shipping Options: (First Class Mail is the no cost default)
First Class Mail
USPS Priority Mail - $15-USA Only
FedEx - $25 (Add $5 for AK or HI) UPS - $30
Waive Signature - FedEx or UPS FedEx/UPS International - $50/$65
IDENTIFICATION REQUIRED - Requestor must submit A) One Primary form of ID; OR B) Two Secondary forms of ID;
OR C) Submit a Notarized application. (Choose A or B or C) - Instructions for identification listed on back of the form)
Date Subscribed and Sworn Before Me
SEAL
Signature of Notary Public
Warning - NDCC 23-02.1-32(c) Penalties. Any person who willfully or knowingly uses or attempts to use or to furnish to another for use,
for any purpose of deception, any certificate, record, report, or certified copy thereof so made, altered, amended or mutilated shall be
guilty of a class C felony.
PLEASE DO NOT ENTER ANYTHING BELOW THE LINE - THIS PORTION FOR OFFICIAL VITAL RECORDS UNIT USE ONLY
Identification Verified Fee Received
My Commission Expires
County State
SFN 8140 (1-2024)
Page 2 of 2
INSTRUCTIONS FOR OBTAINING A CERTIFIED COPY OF A BIRTH RECORD
The Vital Records Unit can issue copies of birth certificates only for births that occurred in North Dakota. We have records
on file starting with 1870 to the present. Proof of identification must be submitted by the requestor before we can issue a
certified copy of a birth record. The requestor must submit legible non-expired copies of either A) One PRIMARY form of
ID; or B) Two SECONDARY forms of ID; or C) Submit a NOTARIZED form. Specific instructions are below for each option:
A) PRIMARY Identification options: (Must show Name, Date of Birth and Expiration Date. If this information is listed
on opposite sides of the ID, then we need a copy of both sides of the ID)
1. State Government issued Photo ID or Driver's License
2. Bureau of Indian Affairs issued tribal ID card
3. US Government issued Military ID card
4. US Government issued Passport or Visa
5. US Government issued Permanent Resident Card
B) Two SECONDARY Identification options: (We cannot accept two of the same documents. i.e., 2 bank statements)
1. Social Security Card
2. Medicare/Medicaid Card
3. Utility bill with the current address (within the last three months)
4. Bank Statement with the current address (within the last three months)
5. Pay Stub (within the last three months) or W-2 (issued for the previous tax year)
6. Motor Vehicle Registration Card for the current year with the current address
7. Tribal Enrollment Record - Issued by a Native American Tribe. Must contain Date of Birth.
8. DD Form 214 - Certificate of Release or Discharge from Active Duty
C) Submit a NOTARIZED form:
1. Requestor MUST sign and date the form in the presence of a Notary Public.
2. The Notary Public must complete all five notary fields on the front of the form.
3. The Notary Public must sign the form and affix their notary seal in the space provided.
The fee for a search of the files is $15; one search fee pays for one certified copy. Please make your check or money
order payable to ND DHHS. We will issue a certified raised-seal paper copy for each copy requested. Once received in our
office, copies are usually mailed in 3 to 5 business days (this does not include the mailing time). Certified copies
CANNOT be faxed or emailed.
The certified copies will be sent by USPS First Class Mail unless you specify and include the additional funds for expedited
shipping options. Copies to be sent by Federal Express*, UPS* or USPS Priority Mail are processed the same day,
provided the request is in our office by 10:00 a.m. Central Time, otherwise they will be processed the next business day.
(*) - Federal Express and UPS cannot be used to send to U.S. PO Boxes
This form may be completed and mailed with fees to:
Department of Health and Human Services
Vital Records
600 East Boulevard Ave. Dept. 325
Bismarck, ND 58505-0250
Our web site is at: www.hhs.nd.gov/vital
For questions, call our office at (701) 328-2360 or e-mail us at [email protected]
