Birth Records are available from 1905 - present.
Certificates may be ordered online at vitalrecords.utah.gov.
Please read this application carefully. It is a criminal violation to make false
statements on this application or to fraudulently obtain a vital records certificate.
All fees paid are non-refundable. If required information is missing from this
application, applicant will have 90 days to provide missing information.
[ ] This application is fully completed.
[ ] My payment is ready. // Mail Orders: Check or Money Order enclosed
[ ] My ID is ready. (See reverse for ID list) // Mail: Copy of ID enclosed
FULL NAME FOR CERTIFICATE ________________________________________________________________________
BIRTH DATE ____________________ BIRTH CITY AND COUNTY ____________________________________________
HOSPITAL OR PLACE OF BIRTH _______________________________________________________________________
PARENT 1 FULL NAME ____________________________________________ BIRTH DATE _____________________
PARENT 2 FULL NAME ____________________________________________ BIRTH DATE _____________________
Relationship to certificate holder: [ ] Self [ ] Parent [ ] Sibling [ ] Spouse [ ] Child [ ] Grandparent [ ] Grandchild
[ ] Other (requires documentary proof of relationship or legal need) Specify: ___________________________________________________
PRINTED NAME _____________________________________________________
PHONE __________________________
ADDRESS ___________________________________________________________________________________________
EMAIL ADDRESS _____________________________________________________________________________________
NUMBER OF CERTIFICATES 1 Search (non-refundable) includes 1 certified copy $20 +
Additional certified copies ($10 each) =
TOTAL FEE
SIGNATURE ________________________________________________________
DATE ___________________________
ID # ______________________________ ID Exp __________ Request # ____________________________
Paid: Check Money Order Cash Credit Card Account Clerk Initials ________
IDENTIFYING INFORMATION
APPLICANT
GENERAL INFORMATION
CHECKLIST
MAILING ADDRESS: PO Box 141012 ◦ SLC, UT 84114-1012 ◦ PHYSICAL ADDRESS: 288 N 1460 W, SLC
801-538-6105 ◦ Fax 801-538-7012 ◦ vreques[email protected] ◦ vitalrecords.utah.gov ◦ UDOH-OVRS-104 Dec 2018
OFFICE USE ONLY
BIRTH CERTIFICATE
APPLICATION
Identification is required for all non-public Vital Records.
Mailed requests must include an enlarged and easily identifiable photocopy of your identification from the list below or
your application will be returned.
If using a form of identification from the “Primary” column, one form of identification is required.
If using a form of identification from the “Secondary” column, two forms of identification are required.
Primary
(Need 1)
Government Issued Photo Drivers License Work Identification/Paycheck/W-2
Government Issued Photo Identification School, University or College Identification Card
Government Issued Work Identification Voter Registration Card
Employment Card Social Security Card
U.S. Military Identification Card U.S. Military Separation/DD-214
Tribal Identification Card Motor Vehicle Registration/Title
Pilot License Marriage License (not issued by Utah State Vital Records)
Alien Registration Card Court Order or Court Documents
Permanent Resident Card Jail/Prison Documents
Temporary Resident Card Probation Documents
U.S. Passport Property Tax Receipt
Foreign Passport Veterans Universal Access Identification Card
U.S. Certification of Naturalization Selective Service Card
Certificate of U.S. Citizenship Hunting/Fishing License
U.S. Citizen Identification Card Insurance Card or Documents
Matricula Consular Card Utility Bill
Concealed Weapon Permit Business License
Mexican Voter Registration Card
Professional License
Jail/Prison Release Form (with picture)
· Novelty Identification Card
· Driving Privilege Card
Secondary
(Need 2)