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 ________
MAILING ADDRESS: PO Box 141012 ◦ SLC, UT 84114-1012 ◦ PHYSICAL ADDRESS: 288 N 1460 W, SLC
801-538-6105 ◦ Fax 801-538-7
012 ◦ vreques
[email protected] ◦ vitalre
cords.utah.g
ov ◦ UDOH-OVRS-104 Dec 2018