Phone: 1-406-775-8749/Fax: 1-406-775-8750
PLEASE READ THESE INSTRUCTIONS CAREFULLY
WHO CAN ORDER A BIRTH CERTIFICATE?
Only those authorized by 50-15-121 MCA, which includes the registrant (14 years old or older), the registrant’s spouse, children, parents, or guardian, or an authorized representative, or those who provide documentation showing it is needed for determination or protection of the individuals personal or property rights, proof of relationship, guardianship, or authorization is required may obtain certify copy of a birth record. Step-relatives, in-laws, grandparents, aunts, uncles, cousins, ex-spouses, and a natural parent of an adoptive child are not eligible to receive a certified copy of a birth certificate.
IDENTIFICATION IS REQUIRED
The person signing the request must provide an enlarged legible photocopy of both sides of their valid driver’s license or other legal picture identification with a signature or the requestor must have this application notarized.
SEE LIST OF ACCEPTABLE IDENTIFICATION
IMPORTANT: If the identification requirement is
NOT met or if the application is incomplete, your request will be returned and
significant delays in processing your order may occur.
FEE (All fees must be
• CERTIFIED COPIES OF A BIRTH CERTIFICATE cost
$5.00 for the first copy, $5.00 for each additional copy of the same record.
(non-refundable)
• INFORMATIONAL COPIES OF A BIRTH CERTIFICATE may
be issued to anyone as long as the birth occurred 30 years prior to the date of
application, the cost is $1.00. (non-refundable)
• CERTIFIED COPIES OF DOCUMENTS on file with
the state (i.e. Acknowledgment of Paternity, correction affidavits), the cost
is $5.00 for the first copy, $5.00 for each additional copy of the same record.
(non-refundable)
Phone: 1-406-775-8749/Fax: 1-406-775-8750
Please complete the following information.
FULL First, Middle and Last Name on Birth Certificate:_______________________________________________________
Has name ever been changed other than marriage _____ No _____ Yes if so original name ________________________________________________
Date of Birth: Place of Birth (City or County):______________________________
Mother’s Full Maiden Name: _______________________________________________
Father’s Full Name:__________________________________________
# of copies needed_________
Your relationship to the certificate holder :__________________( self, mother, father etc)
Reason the Birth Certificate is needed: ______________________________________
Mailing or Delivery Address:
Name: ____________________________________
Applicant’s Signature_____________________________________
Address: _____________________________________________________
City, State, Zip: ________________________________________
Daytime Telephone Number: __________________
Notary_ (For use if needed)________________________________________
Name: _______________________________ personally appeared before me and whose identity I proved on the basis of satisfactory evidence to be the signer of the above instrument.
Subscribed and sworn to before me on this day of _______________ 20____
Signature: ____________________________________
Printed Name: __________________________________
SEAL Notary Public in and for the State of _________________
Residing at _________My commission Expires__________________
NOTICE: STATE LAW PROVIDES PENALTIES FOR PERSONS
WHO WILLFULLY AND KNOWINGLY USE OR
ATTEMPT TO USE THIS CERTIFICATE FOR ANY PURPOSE OF
DECEPTION. (50-15-114, MCA)
Official Use Only
Date ____________________________________
Rec# ___________________________________
Amount _________________________________
Cert #___________________________________
Ser #____________________________________
Comment _______________________________