Application to Request an Alabama Birth Certificate After Surrogate Birth application form pdf

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APPLICATION TO REQUEST A N ALABAMA BIRTH CERTIFICATE AFTER SURROGATE BIRTH When a surrogate birth occurs in Alabama, the Center for Health Statistics must be presented an original, final court order determining the child’s legal parentage. Upon receipt of the final court order providing the required information, the Center for Health Statistics will prepare a new birth certificate for the child showing the child’s name and the name( s) of the legal parent(s). The fee to prepare the new certificate of birth is $25.00 which includes one certified copy of the new record. Additional co pies of the same record ordered at the same time are $6.00 each. There is an additional fee of $15.0 0 to expedite a request. Make check or money order payable to “State Board of Health.” Do not send cash. Fees are non - refundable. Valid identification must be submitted with a request for a new Alabama birth certificate . See the identification requirements on the reverse side. Complete the application below and send with the valid identification and appropriate fee to: Center for Health Statistics Attn: Parentage Clerk P.O. Box 5625 Montgomery, A labama 36103 - 5625 To reduce delay in certificate issuance, the completed application, valid identification and fee may be submitted to the Cent er for Health Statistics while the final court order is in process. However, the new birth certificate cannot be created before the final court order is received by this office. If an Apostille or Exemplified copy is required with the birth certificate, or if you have additional questions, call 334 . 206 . 2637 or visit our website at www.alabamapublichealth.gov/vit alrecords . FULL NAME OF CHILD ________________________________ ________________________________ ________________________________ _________ First Middle Last COUNTY OF BIRTH ______________________________________ HOSPITAL ________________________________ ____________________________ DATE (OR ESTIMATED DATE) OF BIRTH _________________ ___________________ __________ ___ S EX ________________________________ ____ FULL NAME OF LEGAL MOTHER/PARENT ________________________________ ________________________________ ________________________ First Middle Maiden Last Current Last RESIDENCE STATE ( OR FOREIGN COUNTRY ) OF LEGAL MOTHER /PARE NT ________________________________ ___________________________ RESIDENCE COUNTY ( OR FOREIGN PROVINCE ) OF LEGAL MOTHER/PARENT ________________________________ _________________________ FULL NAME OF LEGAL FATHER/PARENT ________________________________ ________________________________ _________________________ First Middle Maiden Last Current Last APPLICANT SECTION (THIS SECTI ON MUST BE COMPLETED) Number of Copies __________ ____ Amount Enclosed $ ________________ Valid identification must be submitted with a request for a new birth certificate. Anyone falsely applying for a record is subject to a penalty upon conviction of up to three months in the county jail or a fine of up to $500. ( Code of Ala bama 1975, § 13A - 10 - 109 ) . By signing, you are certifying you have a legal right to the record requ ested. Your Signature ____________________________________________________________ ________ __ Date ________________________________ _____ Print Your Name ________________________________ ________________________________ ________________________________ ______________ Your Relationship to Child ________________________________ ________________________________ ________________________________ _______ Mail to Name (if Different from You) ________________________________ ________________________________ _______________________________ Mailing Address ________________________________ ________________________________ ________________________________ __ City _________________________________ State _____________ Zip _________________ Daytime Phone (_________) _________________________ I allow the following individual to receive the certificate(s) ________________________________ ________________________________ ______________ ADPH - HS - 103 – 2/7/2020 IDENTIFICATION REQUIREMENTS FOR RESTRICTED ALABAMA VITAL RECORDS Identification is required of any applicant requesting a restricted Alabama vital record (birth certificate less than 125 years from the date of birth or death certificate less than 25 years from the date of death). The applicant must submit a completed r equest and one form of identification from the Primary ID list below. In the event the applicant is unable to provide identification from the Primary ID list, he/she may provide two different forms of identification from the Secondary ID list. If the app licant designates another individual to pick up a restricted certificate on his/her behalf, both the applicant and the designee must provide acceptable identification. The completed request, as well as a copy of all identification submitted, will be maint ained by the vital records office which processes the request. Primary IDs Including PHOTO (need at least one, current, expired no more than 60 days) Secondary IDs (need at least two) - Alabama Driver’s License - Out - of - State Driver’s License - State - Issued Non - Driver ID - U.S. or Foreign Passport - U.S. Certificate of Naturalization - Certificate of Citizenship - U.S. Military ID - Work ID (If applicant is employee of agency/company mak ing request) - Alien Resident Card (Temporary or Permanent) - U.S. Employment Authorization Card - Citizenship ID Card - Tribal ID - Pilot’s License - Boating License - Concealed Weapons License - Ex - Felon ID - Inmate ID issued by the U.S. Dept of Justice w/ following documentation: o Supporting documents from institution if inmate is still in custody, letter of release from institution if inmate has been released - School ID (Must include current school term) - Alabama Voter Identification Card - Expired, Government - Issued ID - Utility Bill (No more than 6 months old) - Work ID (If applicant is making personal request) - Vehicle Registration or Vehicle Title - Property Tax Bill - Military Discharge (DD Form 214) - Voter Registration Card - Health Insurance Card - Social Security Corresponde nce (not Card) - U.S. Selective Service Card - Recent DMV Receipt for Fines Paid - Fishing or Hunting License - Copy of Police Report or other official documents which support theft, in cases where individual’s ID has been stolen - Autism Spectrum Card - Immunization (Shot) Record * In special cases where applicant is unable to provide any of these documents, please contact CHS at 334.206.5418.