Free 49607.FH11 - Indiana

APPLICATION FOR SEARCH AND CERTIFIED COPY OF BIRTH RECORD
State Form 49607 (R3 / 10-07) Approved by State Board of Accounts, 2007

INDIANA STATE DEPARTMENT OF HEALTH

BIRTH RECORDS IN THE STATE VITAL RECORDS OFFICE BEGIN WITH OCTOBER 1907. Prior to October 1907, records of birth are filed ONLY with the local health department in the county where the birth actually occurred. FEES ARE ESTABLISHED BY LAW (IC 16-37-1-11 and IC 16-37-1-11.5). Each search for a record costs $10.00. The fee is non-refundable. Included in one search is a 5-year period: the reported year of birth and, if the record is not found in that year, the 2 years before and after. A certified copy of the record, if found, is included in the search fee. Additional copies of the same record purchased at the same time are $4.00 each. Amendments made to the record are an additional $8.00. WARNING: FALSE APPLICATION, ALTERING, MUTILATING, OR COUNTERFEITING INDIANA BIRTH CERTIFICATES IS A CRIMINAL OFFENSE UNDER IC 16-37-1-12. IDENTIFICATION IS REQUIRED according to IC 16-37-1-7 (e.g., photocopy of drivers license, work identification card, etc.). Requests for birth certificates sent without proper identification will be returned to the requester without processing. Please complete all items below as required pursuant to IC 16-37-1-10 (a):
Full name at birth Could this birth be recorded under any other name? If yes, please give name. Has this person ever been adopted? If yes, please give name AFTER adoption. Place of birth: City Name of hospital Date of birth (month, day, year) Full name of father (If adopted, give name of adopted father.) Full name of mother including maiden name (If adopted, give name of adopted mother.) Purpose for which record is to be used Your relationship to the individual named on the requested certificate Total certificates Total fee(s) Age last birthday Place of birth: County

Standard size: __________ Wallet size: ___________
Delivery preference

Regular Mail
Signature of applicant

Express Courier (requires an additional fee)

Pickup

Customer Waiting

Mailing address (number and street, city, state, and ZIP code) Daytime telephone number (including area code) Todays date (month, day, year)

Send this application, check or money order payable to the Indiana State Department of Health, and a copy of your identification to: Vital Records, Indiana State Department of Health, PO Box 7125, Indianapolis, IN 46206-7125. PRINT name and address of person to whom the certified copy is to be mailed if different than stated above.
Name Mailing address (number and street, city, state, and ZIP code)

FOR OFFICE USE ONLY
Date received (month, day, year) Certificate number Receipt number Application number Volume number Initials of verifier

Your fee of $ ___________ has been received and is being held pending receipt of information requested. Please remit additional fee of $ _____________.

A.

The following individuals are eligible to receive a copy of a birth certificate: 1. 2. 3. 4. 5. 6. 7. 8. 9. Individual named on the certificate (18+ years. If under 18 years of age, signature, ID, and telephone number of parent or legal guardian must be provided.) Mother of the individual named on the certificate. Father (if named, married to mother or paternity established) of the individual named on the certificate. Maternal grandparents of the individual named on the certificate. Paternal grandparents of the individual named on the certificate if the fathers name is on the record of birth. Any individual presenting Guardianship Papers on the individual named on the birth certificate. Brothers and sisters of the individual named on the birth certificate if both parties are over 18 years of age. Maternal aunts and uncles of the individual named on the certificate. Paternal aunts and uncles of the individual named on the certificate if the fathers name is on the record of birth.

10. Spouse of the individual named on the certificate. 11. Son, daughter, or grandchild (18 years of age) of the individual named on the birth certificate. B. The following information must be included in order for a search to be completed: 1. 2. 3. 4. 5. C. Full name, place, and date of birth, parents full names, including mothers maiden name. Written signature of applicant. A photocopy of signature identification (e.g., drivers license) of the applicant. Do not send original identification by mail. Return address and telephone number of applicant. A check or money order payable to the Indiana State Department of Health for the correct fee(s).

Any additional questions may be directed to 317-233-2700.