APPLICATION FOR CERTIFIED MISSISSIPPI BIRTH CERTIFICATE
Mississippi State Department of Health
Post Office Box 1700, Jackson, Mississippi 39215-1700
Requirement for ordering: If applicant is self, spouse, parent, grandparent, sibling, child, grandchild, guardian, or legal representative, then this application
must be completed and a copy of a valid photo identification of the applicant must be provided. Acceptable forms of identification are the following:
Driver’s License, State Identification Card, Passport, and/or Military Identification Card, (See back for other acceptable forms). Guardian or legal representative
must submit proof or guardianship/legal representation with this application.
Child’s Full Name on
If Name Changed Since
Birth, Give New Name
Date of Birth
STATE FILE NUMBER (IF KNOWN)
Place of Birth
CITY OR TOWN
Mother’s Maiden Name
(Name Before Marriage)
ABIRTH RECORD SEARCH REQUIRES ADVANCE PAYMENT OFANON REFUNDABLE SEARCH FEE OF $15.00 AND VALID PHOTO IDENTIIFICATION.
The $15.00 fee entitles the applicant to one Certified copy of the birth record on file
(November 1, 1912 to present) or if the record is not found, a “Not on File” statement
will be issued. Contiguous counties and five years centered on year of birth are
searched if record is not located within county or year specified.
Additional Certified copies of the same certificate ordered at the same time.
$5.00 for each additional certified copy.
TOTALAMOUNT ENCLOSED. Check or Money Order payable to Mississippi
Vital Records. (DO NOT SEND CASH). International payments should be made
by Cashiers Check or Money Order in U. S. Dollars. Mississippi law allows an
additional Service charge for dishonored checks.
APPLICANT NAME/DELIVERY INFORMATION
Pursuant to Section 41-57-2 of the Mississippi Code of 1972, Annotated and as defined by Mississippi State Board of Health Rule