Birth Certificate Application
Complete this form to order a certified copy of a Minnesota birth certificate.
You must fill in the information we ask for on this form. We need the information to find the correct birth record
and to make sure that you may receive the certificate. If we cannot find the birth record you asked for, we will
send you a certified “Statement of No Birth Record Found”. Minnesota Rules, part 4601.2600
Information to find the requested birth record
Minnesota Rules, part 4601.2600, subpart 2
Child/Subject
Child/subject first name
Child/subject last name
Name suffix
Date of birth (MM/DD/YYYY)
Sex
☐ Female
☐ Male
Minnesota city of birth
Minnesota county of birth
State of birth
MN
Parents
Parent one first name
Parent one middle name
Parent one last name
Last name before 1
st
marriage
Name suffix
Parent two first name
Parent two middle name
Parent two last name
Last name before 1
st
marriage
Name suffix
Requester - person completing this application
Minnesota Rules, part 4601.2600, subpart 3
Requester
Requester full name
Date of birth (MM/DD/YYYY)
Daytime phone (10-digit)
Requester mailing address – street
Apt/Unit #
Email
City
State
ZIP Code
MANDATORY — Check the boxes below that describe your relationship to the subject of the record:
Marital status is important.
Records of children born to married parents are “public”. That means that the certificate is available to those listed in items 1 – 18
below. Records of children born to single mothers are “confidential” unless the mother chose to make the record public at the time of
birth. Only the persons listed below in items 19 – 23 may obtain confidential birth certificates.
Minnesota Statutes, section 144.225, subdivisions 2 and 7.
“Public” birth records are available to individuals who meet any of the legal requirements in items 1-18
1. ☐ A parent named on the subject’s record
2. ☐ A grandparent of the subject
3. ☐ A great grandparent of the subject
4. ☐ A child of the subject
5. ☐ A grandchild of the subject
6. ☐ A great-grandchild of the subject
7. ☐ Spouse of the subject (You must be the current spouse)
8. ☐ I am the subject; I am requesting my own birth record
9.
☐ The legal custodian, guardian, or conservator of the subject (we need a certified copy of the court order that names you)
10.
☐ The health care agent for the subject (we need a valid “health care power of attorney” document)
11.
☐ Subject’s personal representative who requires the birth certificate for administration of the subject’s estate
12.
☐ Successor of a deceased subject who requires the birth certificate for administration of the subject’s estate
13.
☐ Person who demonstrates a need for a birth certificate to determine or protect a personal or property right
14.
☐ Adoption agency — to complete post-adoption search (we need a copy of your Employee ID)
15.
☐ Local/state/tribal or federal governmental agency (we need a copy of your Employee ID) (Best practice: wait for family to verify the record).
16.
☐ Attorney – I represent the subject, or a person listed in items 1-14 above.
My Minnesota Attorney License Number is: _________________________
If you are a NON-Minnesota attorney,
attach a copy of your attorney license.
17.
☐ Pursuant to a valid, certified copy of a U.S. court order (not a subpoena) releasing the certificate
18.
☐ I have a signed statement from a person above; it specifies the subject’s full name, date of birth, parents’ names, the signer’s
relationship to the subject of the record and it authorizes me to obtain the certificate.
“Confidential” birth records are available only under the conditions, or to the person, in items 19-23
19.
☐ Parent named on the subject’s record
20.
☐ The legal custodian, guardian, or conservator of the subject (you need a certified copy of a court order naming you)
21.
☐ The subject, when 16 years old or older
22.
☐ Representatives of Minnesota programs that administer child support, medical assistance, MinnesotaCare, and services under
Minnesota Statutes, sections 124D.23; Minnesota Statutes, chapter 260E; and, tribal child support programs, Minnesota
Statutes, section 144.225, subdivision 2, paragraph (f). (we need a copy of your Employee ID)
23.
☐ Pursuant to a valid, certified copy of a U.S. court order (not a subpoena) releasing the certificate
B I R T H C E R T I F I C A T E A P P L I C A T I O N
6/2023
Person completing this application – the requester:
Requester’s signature and signature of notary public
By signing my name in the space below, I hereby attest that the information I am providing on this application is correct to
the best of my knowledge and belief and that I meet the legal requirements indicated in Section C.
Requester’s signature (Signature must match the name of the requester on page one)
Notary Stamp/Seal
Signed or attested before me on: ________ day of _____ , 20 ___
Printed name of notary public
Notary public signature
My commission
expires
How many birth certificates do you want?
Fee
Subtotals
One certified birth certificate
$26
$26
Added copies are $19 each if you buy them at the same time as one at $26.
# of added
copies
$19
each
How many VA birth certificates do you want?
Minnesota Statutes, section 197.63, subdivision 1
VA birth certificates are available free - for Veterans Affairs related purposes only
# VA certificates
$0
The amount you pay must cover the certificates and services you requested above.
Amount due
Payment due
(Must be $26 or more)
How do you want to pay?
Fees are due with the application and are non-refundable. Minnesota Statutes, section 144.226.
☐ Credit card
MasterCard/VISA/Discover
Cardholder name
Valid thru MM/YY
Card number
3-digit security code
☐ Check
Check #
Make check or money order payable to Dakota County and send by
mail with application. DO NOT SEND CASH.
Checks returned for non-payment will result in a $30 charge to you. You
could also face civil penalties. Minnesota Statutes, section 604.113,
subdivision 2.
☐ Money order
Money order #
Send your application and payment to:
Northern Service Center
Service Desk
1 Mendota Road West
Suite 130
West St. Paul, MN 55118
If you have questions, contact nscservic[email protected] or call 651-554-6531.