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  REQUESTS













Birth Certificate Request
State Center for Health Statistics Administration
For District of Columbia Occurrences Only 
 
Mail-In Form     (Click here for Instructions)
1. Certificate Holder's Name:
(First)     (Middle)     (Last)
2. Birth Date: / / (mm/dd/yyyy)
3. Sex:  Male  Female
4. Hospital:
5. City: Washington, DC
6. Father's Name:
(First)     (Middle)     (Last)
7. Mother's Maiden Name:
(First)     (Middle)   (Maiden)
8a. Number of Original Certificate Forms Requested:   
      $23.00 each Total Cost: $
8b. Number of Computer Certificate Short Forms Requested:  
      $18.00 each Total Cost: $
8c. Total Amount Enclosed:  $
9. Relationship to Certificate Holder: Self  Mother  Father   Other    
10. Signature of Requester:  _____________________________________
11. Date:  _________/_________/_________ (mm/dd/yy)
Mail Certificate(s) to:
12. Name:
13. Address:
14. City/State/Zip Code::
15. Day Phone: (Required)
* Copy of Requester's Photo ID Required.
If record is not located a "Certificate of Search" will be issued.

Instructions to be completed:
1. Print, sign, enclose requestor's photo ID and date the form
2. Enclose check or money order payable to DC Treasurer
3. Mail to:

Department of Health
Vital Records Division
825 North Capitol Street, NE, 1st Floor
Washington, DC 20002
(202) 671-5000

 

Birth Application Instructions

The birth certificate request form contains 12 questions. A separate copy of the request form should be completed for each person whose birth record is being requested. However, multiple copies of a single birth record may be requested on the same form.

Items 1-7: Personal information about the certificate holder.

Item 8a: Please indicate the total number of original form certificates that you are requesting. To calculate the total cost, multiply the number of requested certificates by $23.

Item 8b: Please indicate the total number of computer-generated short-form certificates that you are requesting. To calculate the total cost, multiply the number of requested certificates by $18.

Item 8c: Please indicate the total amount of money that you are enclosing. To calculate this amount, you should add the total cost of the original-form certificates to the total cost of the short-form certificates. (See items 8a and 8b.) If you send your request by mail, please enclose a check or money order payable to the DC Treasurer.

Item 9: The relationship of the requester to the certificate holder.

Items 10-11: The person who is requesting the certificate(s) must sign and date the request and enclose a photocopy of his or her official picture identification card. 

Items 12-15: Information about the designated recipient of the certificate(s).

After you have printed out and signed your request, mail it with your payment to:

Vital Records Division
825 North Capitol Street, NE, First Floor
Washington, DC 20002
(202) 671-5000

If record is not located a "Certificate of Search" will be issued.