APPLICATION FOR FLORIDA BIRTH RECORD
(For Headquarters Use Only)
Requirement for ordering: If applicant is self, parent, guardian, or legal representative, then the applicant must complete this application and provide photo identification.
If applicant is not one of the above, the Affidavit to Release A Birth Certificate must be completed by an authorized person and submitted in addition to this application form.
Acceptable forms of identification are the following: Driver’s License, State Identification Card, Passport, and/or Military Identification Card.
TYPE OR PRINT
FULL NAME AT BIRTH
If name was changed since
birth, indicate new name
PLACE OF BIRTH - CITY
BIRTH FILE NUMBER (if known)
DATE OF BIRTH
YEAR (4 DIGIT)
IF YEAR IS NOT KNOWN
ENTER RANGE OF YEARS TO
BE SEARCHED IN NEXT BOX
(Name before marriage)
IMPORTANT: Read the entire application before completing.
To obtain and use a Florida birth record under false or fraudulent purposes is a third-degree felony punishable by the terms and conditions
set forth in Florida Statutes.
A BIRTH RECORD SEARCH REQUIRES ADVANCE PAYMENT OF A NON-REFUNDABLE SEARCH FEE OF $9.00
The $9.00 fee entitles the applicant to one computer certification of a registered birth (1930 to
present) or if a record is not found a certified “No Record Found” statement will be issued.
If a PHOTOCOPY is requested in lieu of a computer certification for computer years an
additional charge of $5.00 is required, making first photocopy fee $14.00.
Additional copies of the same type certification ordered above are $4.00
each, when ordered with this request
ADDITIONAL YEAR(s) SEARCH a fee of $2.00 per year. Maximum
search fee is $55.00 regar