2. 
3. Birth Certificate Payment Form
5. First Name on Birth Certificate*
6. Last Name on Birth Certificate*
8. Date of Birth*
9. Place of Birth *

   County, City, and State are required

11. Relationship to Person Listed on Birth Certificate*
    -- Select One --ParentChild ofSiblingGrandparentGrandchildGuardianSelf

    Additional identification or proof of relationship may be required.

12. Identification*

    Upload a picture of your valid government issued photo ID.

14. Parents full names*

    Provide the names of both Parent 1 and Parent 2 including maiden name, if either Parent was known by a different name.

16. Phone Number*
17. Email Address*
19. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
21. Electronic Signature
23. Mailing Address*
25. Mailing City*
26. Mailing State*
27. Mailing Zip*
29. Birth Certificate (Full Size)
    Certified Copy
30. Price
31. Quantity
    Limit 5 per year
32. Shipping Cost
34. Birth Certificates (Wallet Size)
    Certified Copy
35. Price
36. Quantity
    Limit 5 per year
37. Shipping Cost
39. Online Payment Fees:

    Online payments are processed by Forte. A fee of 2.55% or $1.55 (whichever is greater) will be assessed for all credit card payments. Electronic Checks are also accepted, and will be assessed a flat $1.25 for any payment under $50,000. The appropriate fee will be added to the total cost of your payment.

41. Taxable
42. Taxable
Leave This Blank:


43. Calculate Totals Proceed to Checkout

* indicates a required field