Birth Certificate Request*
State Center for Health Statistics Administration
For District of Columbia Occurrences Only 
 

Mail-In Form	(Click here for Instructions)
1. Certificate Holder's Name:	(First)     (Middle)     (Last)
2. Birth Date:	/ / (mm/dd/yyyy)
3. Sex:	Male  Female
4. Hospital:
5. City:	Washington, DC
6. Father's Name:	(First)     (Middle)     (Last)
7. Mother's Maiden Name:	(First)     (Middle)   (Maiden)
8a. Number of Original Certificate Forms Requested:
$23.00 each		Total Cost: $
8b. Number of Computer Certificate Short Forms Requested:
$18.00 each		Total Cost: $
8c. Total Amount Enclosed:* *	$
9. Relationship to Certificate Holder:	Self  Mother  Father   Other
10. Signature of Requester:		_____________________________________
11. Date:		_________/_________/_________ (mm/dd/yy)
Mail Certificate(s) to:
12. Name:
13. Address:
14. City/State/Zip Code::
15. Day Phone: (Required)
* Copy of Requester's Photo ID Required. If record is not located a "Certificate of Search" will be issued.   **Beginning January 1, 2009, all mail-in requests must include a stamped self addressed No. 10 (4 1/8" x 9 1/2") business size return envelope.  **The DC Treasurer requires that all checks have an address imprinted on them to be accepted for deposit.
Instructions to be completed: 1. Print, sign, enclose requestor's photo ID and date the form 2. Enclose check or money order payable to DC Treasurer 3. Mail to: Department of Health Vital Records Division 825 North Capitol Street, NE, 1st Floor Washington, DC 20002 (202) 671-5000
Birth Application Instructions The birth certificate request form contains 12 questions. A separate copy of the request form should be completed for each person whose birth record is being requested. However, multiple copies of a single birth record may be requested on the same form. Items 1-7: Personal information about the certificate holder. Item 8a: Please indicate the total number of original form certificates that you are requesting. To calculate the total cost, multiply the number of requested certificates by $23. Item 8b: Please indicate the total number of computer-generated short-form certificates that you are requesting. To calculate the total cost, multiply the number of requested certificates by $18. Item 8c: Please indicate the total amount of money that you are enclosing. To calculate this amount, you should add the total cost of the original-form certificates to the total cost of the short-form certificates. (See items 8a and 8b.) If you send your request by mail, please enclose a check or money order payable to the DC Treasurer. The DC Treaurer requires that all checks have an address imprinted on them to be accepted for deposit. Item 9: The relationship of the requester to the certificate holder. Items 10-11: The person who is requesting the certificate(s) must sign and date the request and enclose a photocopy of his or her official picture identification card.  Items 12-15: Information about the designated recipient of the certificate(s). After you have printed out and signed your request, mail it with your payment to: Vital Records Division 825 North Capitol Street, NE, First Floor Washington, DC 20002 (202) 671-5000 If record is not located a "Certificate of Search" will be issued.