GENESEE COUNTY CLERK

APPLICATION FOR BIRTH RECORD

(Please Print)

APPLICANT INFORMATION (Person Requesting Record)

YOU MUST ATTACH A COPY OF YOUR DRIVER LICENSE OR STATE ISSUED ID

Applicant's Name: _____________________________________________________________________

Address: ____________________________________________________________________________

City/State/Zip_________________________________________________________________________

Daytime phone number to contact you if there is a problem: ( ) ____________________________

APPLICANT'S SIGNATURE:

________________________________________________________
Must be Signed in Order to Process

ELIGIBILITY - Are you eligible to request this birth record?

Please check the box that applies to you:
ELIGIBILITY: Michigan law limits who can receive a certified copy of a Michigan birth record. You must
select which category qualifies you to receive the requested record. YOU MUST INCLUDE A COPY OF
YOUR DRIVERS LICENSE OR STATE ISSUED ID WITH YOUR REQUEST.

PERSON NAMED ON RECORD PARENT NAMED ON RECORD

REQUESTED BIRTH INFORMATION

Name at Birth: _______________________________________________________________________

First Middle Last

Date of Birth: ___________________________ Place of Birth: ______________________________

Month Day Year City County

Mother’s Name: ______________________________________________________________________

First Middle Maiden

Father’s Name: ______________________________________________________________________

First Middle Last

The fee is $25.00 for the first copy, and $10.00 for EACH ADDITIONAL COPY of the same record when
ordered at the same time as the first copy. If the birth record is yours and you are 65 or older the fee is
$5.00 for each copy requested.

Number of Copies Requested: ____________

Mail this application with a MONEY ORDER payable to:

Genesee County Clerk

Vital Records
900 S. Saginaw St.
Flint, MI 48502

For additional information call (810) 257-3225