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Get PA H105.102 2020

Application for a Birth Certificate H105. 102 REV 06/18 BIRTH INTERNAL USE ONLY Initials Date Delivery Print or Type P PO M S R A PART 1 APPLICANT My current legal name First Middle Street Last Suffix Email address City Zip code State Daytime phone Applicants must be 18 years of age or older or an emancipated minor to apply. MY RELATIONSHIP TO PERSON NAMED ON BIRTH RECORD Intended use of birth certificate Social Security/benefits Travel/passport School Driver s license Dual citizenship Employment Other PART 2 BIRTH CERTIFICATE BEING REQUESTED Please complete as much information as possible. Please specify other reason. AGE NOW NAME AT BIRTH If name has changed since birth due to adoption court order or any reason other than marriage please list that name here TYPE OF BIRTH RECORD DATE OF BIRTH SEX Male Female PLACE OF BIRTH Born in Pennsylvania City/borough/township County Hospital name PARENT/MOTHER S NAME Last name prior to first marriage Current last PART 3 ACCEPTABLE FORMS OF IDENTIFICATION I have included a legible photocopy of one of the following A valid driver s license or other government-issued photo ID that includes my mailing address. Application for a Birth Certificate H105. 102 REV 06/18 BIRTH INTERNAL USE ONLY Initials Date Delivery Print or Type P PO M S R A PART 1 APPLICANT My current legal name First Middle Street Last Suffix Email address City Zip code State Daytime phone Applicants must be 18 years of age or older or an emancipated minor to apply. MY RELATIONSHIP TO PERSON NAMED ON BIRTH RECORD Intended use of birth certificate Social Security/benefits Travel/passport School Driver s license Dual citizenship Employment Other PART 2 BIRTH CERTIFICATE BEING REQUESTED Please complete as much information as possible. Please specify other reason* AGE NOW NAME AT BIRTH If name has changed since birth due to adoption court order or any reason other than marriage please list that name here TYPE OF BIRTH RECORD DATE OF BIRTH SEX Male Female PLACE OF BIRTH Born in Pennsylvania City/borough/township County Hospital name PARENT/MOTHER S NAME Last name prior to first marriage Current last PART 3 ACCEPTABLE FORMS OF IDENTIFICATION I have included a legible photocopy of one of the following A valid driver s license or other government-issued photo ID that includes my mailing address. If applying by mail the address on my ID matches the mailing address listed above. Expired IDs cannot be accepted* I do not have a valid government-issued photo ID. Therefore I have provided two current documents that verify my name and current address such as a utility bill pay stub bank statement car registration or lease/rental agreement. See www. health. pa*gov/MyRecords/Certificates for further information* Make check or money order payable to VITAL RECORDS* Quantity required 20. 00 Certificate cost X Quantity Total Fee waiver Request member of the U*S* armed forces The fee is waived if the applicant is requesting the certificate for self spouse or a dependent child.

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