Please follow the instructions below when submitting your
Please note: THE D.C. REGISTRAR MAY, AT ANY TIME, REQUEST ADDITIONAL DOCUMENTATION TO
HELP DETERMINE THE IDENTITY OR ELIGIBILITY OF THE APPLICANT.
1. A separate application form must be submitted for each individual certificate being requested, and a separate VitalChek Processing Fee is required for each
separate application. (“LexisNexis VitalChek Network Inc. is in partnership with the District of Columbia Dept. of Health to enable enhanced electronic
processing of mail-in vital record applications.”)
2. Current identification (as listed on the table below) is required for each certificate being requested. Expired IDs will not be accepted.
Choose 1 Primary ID and at least 2 Secondary IDs
PRIMARY ID (1)
State-issued driver’s
license
State-issued non-
driver’s ID card
Passport or Passport Card
Employment
Authorization Card
Permanent Resident Card Military ID Card Law Enforcement ID Department of State Card Government Employee ID
AND
SECONDARY ID
(2 or more)
Copy of Signed Social Security Card Unexpired Vehicle Registration/Title
Social Security Disbursement Statement Copy of Utility bill dated within last 60 days
Certified court documents Copy of Pay stub within last 30 days
Official correspondence from US Citizenship and
Immigration Services
Hospital Newborn Discharge document related to a birth
occurring within the last year
Previous year’s W2
3. Only the persons named on the certificate (Mother/Parent, Father/Parent, or Adult Child), or a person entitled per the chart below are eligible to
receive DC birth certificates. If you are not one of the persons named on the birth certificate, you must also send additional documentation (as shown
below) with your completed application to prove your relationship to the person named on the certificate or your legal need to the certificate.
Relationship to Person
Named on Certificate
Additional Documentation Required
(in addition to the required identification listed above)
Sibling or Adult Child
Your certified birth certificate* supporting the stated relationship
t
Grandparent
Your child's birth certificate* supporting the stated relationship
t
Adult Grandchild
Your birth certificate* AND your parent(s) birth certificate*t supporting the stated relationship
t
Legal Guardian/Custodian
A certified court order, naming you as legal guardian or legal custodian
Social Worker
Typed letter on your firm's letterhead displaying your name and authorizing retrieval of the record, your
unexpired government issued photo ID, valid social worker license and a signed DC Vital Records application
attesting to the identity of the client.
Attorney
Copy of retainer agreement, bar card and typed letter on firm’s letterhead authorizing retrieval of the record.
Power of Attorney
A notarized specific and limited Power of Attorney limiting the power of attorney to five (5) business days and
requesting to receive a certified birth certificate.
Law Enforcement
Typed letter on agency letterhead displaying your name and sufficiently identifying the administrative purpose
or direct & tangible interest** , or a DC Superior Court subpoena or other court order ordering issuance AND
your unexpired government issued photo ID
4. If the record you requested is not located, a “Certificate of Search” will be issued. As the request was processed and the certificate was searched for,
both the Agency Certificate Fee and the VitalChek Processing Fee are non-refundable.
5. Please mail your completed application, along with identification and additional documentation (if required) to:
Vital Record Mail Services
ATTN: DC Vital Records
P.O. Box 222130
El Paso, TX 79913
6. Please allow 5 - 7 business days for your application to be received prior to calling our customer service department with any questions about your
application. We can be reached at 1-877-572-6332.
For expedited order placement
and processing please visit
www.VitalChek.com.
Birth Certificate Application
Please do not include a pre-paid express mail envelope with
your request. This will cause a delay in delivery.
You must select a delivery method on the next page.
• You must provide a legible photocopy or electronic image.
• If the name on the identification does not match the name on the certificate, the applicant must provide evidence of a legal name
change. This may include a certified marriage certificate, certified divorce decree or a certified legal name change court order that reflects
the history of the changes to the name(s) on the certificate(s) requested.
t
may include a certified marriage certificate, certified divorce decree or a certified legal name change court order that reflects the history of the
changes to the name(s) on the certificate(s) requested.
* For births that occurred in DC you do not need to provide your certificate. For births occurring outside of DC, you will need to provide a
certified birth certificate as proof of relationship.
Full Name of Child at Time of Birth (Certificate Holder)
first name middle name last name suffix
Father’s Full Name
first name middle name last name suffix
Mother’s Full Name
first name middle name maiden last name
Date of Birth (MM/DD/YYYY) Hospital Gender Male Still Living Yes
Female No
Reason for Request
Your Full Name (Applicant)
first name middle name last name suffix
Your Street Address City State Zip Code
Your Relationship to Person Named on Certificate E-mail Address (for communication & status updates) Daytime Phone Number
Name and Address to Send Certificate (if different than noted above)
first name middle name last name suffix
Ship To Address City State Zip Code
Your Signature (Applicant) Date of Application
Qty
Price/ea
Total
NUMBER OF COPIES:
First copy
1
$23.00
$23.00
Additional copies (max 5) x $23.00
A
TOTAL FOR ALL COPIES ABOVE
$
SELECT DELIVERY METHOD (choose one):
•
UPS will not deliver to a P.O. Box
•
Processing time may take 7-10 business days
UPS Next Day Air
$20.00
UPS Alaska, Hawaii, Puerto Rico
$40.00
UPS to Canada or Mexico $26.00
UPS Worldwide Expedited $36.50
U.S. Postal Service Regular Mail $0.00
B TOTAL FOR SELECTED DELIVERY
$
C
TOTAL FOR VITALCHEK PROCESSING AND
HANDLING FEE (non-refundable)
$
6.00
TOTAL AMOUNT DUE =
A + B + C
$
FOR VITALCHEK USE ONLY
Order # __________________
STEP 1: CERTIFICATE INFORMATION
STEP 2: YOUR INFORMATION AND SHIPPING ADDRESS
Restriction on Access to Birth Certificates: Pursuant to D.C. Official Code § 7–231.25 (e)(2), the Vital Records Division may issue a certified
copy of a birth certificate ONLY to an applicant that is entitled to the requested birth certificate.
NOTE: This form should be used ONLY by a person who is entitled to the birth certificate.
STEP 3: COST
STEP 4: PAYMENT INFORMATION
Select Payment Method:
Submit separate payment for each Application
Credit Card Personal Check Money Order
DO NOT SEND CASH
Credit Card Information: (if paying by Credit Card)
Credit Card Number Expiration Date
Cardholder’s Signature Date
Charges will appear on your Credit Card statement as: VCN DC VITAL RECORDS
If paying by check or money order, make payable to VITALCHEK.
STEP 5: MAIL YOUR SIGNED AND COMPLETED FORM
For expedited order placement and processing please visit www.VitalChek.com.
Jan 2020
Please mail your completed form, along with ID and additional documentation
(if required) to:
Vital Record Mail Services
ATTN: DC Vital Records
P.O. Box 222130
El Paso, TX 79913
Birth Certificate
Application
Please do not include a pre-paid express mail
envelope with your request. Select a delivery
method from the box to the left.