PLEASE READ THESE INSTRUCTIONS CAREFULLY

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PLEASE READ THESE INSTRUCTIONS CAREFULLY

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DAWSON COUNTY CLERK & RECORDER 207 W Bell St Glendive, MT 59330 406-377-3058 County Application PLEASE READ THESE INSTRUCTIONS CAREFULLY WHO CAN ORDER A BIRTH CERTIFICATE? Only those authorized by 50-15-121 MCA, which includes the registrant (14 years old or older), the registrant’s spouse, children, parents, or guardian, or an authorized representative, or those who provide documentation showing it is needed for determination or protection of the individuals personal or property rights, proof of relationship, guardianship, or authorization is required may obtain certify copy of a birth record. Step-relatives, in-laws, grandparents, aunts, uncles, cousins, ex-spouses, and a natural parent of an adoptive child are not eligible to receive a certified copy of a birth certificate. IDENTIFICATION IS REQUIRED The person signing the request must provide an enlarged legible photocopy of both sides of their valid driver’s license or other legal picture identification with a signature or the requestor must have this application notarized. Suggested Identification Picture ID with a Signature OR Two Forms of ID – One MUST have a Signature OR • Driver’s License • Social Security Card • Credit/Debit/ATM Card • Notarized Montana Office of Vital Statistics Statement to Identify certified • State ID Card • Work ID Card • School ID Card Birth or Death Certificate Applicant form • Passport • Car registration/Insurance • Library Card (you must provide ...

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DAWSON COUNTY CLERK & RECORDER

207 W Bell St

Glendive, MT

59330

406-377-3058

County Application

PLEASE READ THESE INSTRUCTIONS CAREFULLY

WHO CAN ORDER A BIRTH CERTIFICATE?

Only those authorized by 50-15-121 MCA, which includes the registrant (14 years old or older), the registrant’s spouse, children, parents, or guardian, or an authorized

representative, or those who provide documentation showing it is needed for determination or protection of the individuals personal or property rights, proof of

relationship, guardianship, or authorization is required may obtain certify copy of a birth record.

Step-relatives, in-laws, grandparents, aunts, uncles, cousins, ex-spouses, and a natural parent of an adoptive child are not eligible to receive a certified copy of a birth

certificate.

IDENTIFICATION IS REQUIRED

The person signing the request must provide an enlarged legible photocopy of both sides of their valid driver’s license or other legal picture identification with a

signature or the requestor must have this application notarized.

Suggested Identification

If a picture ID with a signature is not available, two other forms of identification are required; one

MUST

have a signature.

IMPORTANT: If the identification requirement is NOT met or if the application is incomplete, your request will be returned

and significant delays in processing your order may occur.

Picture ID with a Signature

OR Two Forms of ID – One MUST have a Signature

•

Driver’s License

•

State ID Card

•

Passport

•

Military ID Card

•

Tribal

•

Social Security Card

•

Work ID Card

•

Car registration/Insurance

•

Doctor/Medical record

•

Fishing License

•

US Military DD214

•

Utility Bill with a current address

•

Voter Registration Card

•

Credit/Debit/ATM Card

•

School ID Card

•

Library Card

•

Insurance Record

•

Pay Stub

•

Traffic/ Pawn ticket

•

Court record

•

Year Book

•

Notarized Montana Office of Vital

Statistics Statement to Identify certified

Birth or Death Certificate Applicant form

(you must provide the original letter, not a

photocopy or faxed copy)

•

Have an authorized family member that

has an ID order the certificate

FEE (All fees must be U.S. funds)

•

CERTIFIED COPIES OF A BIRTH CERTIFICATE

cost $5.00 for the each copy

. (non-refundable)

•

WALLET-SIZE

Cost $6.00 for each copy

(The acceptance of the wallet size certificate is determined by the judicial or administrative body before whom the

certificate is offered as evidence)

•

INFORMATIONAL COPIES OF A BIRTH CERTIFICATE

may be issued to anyone as long as the birth occurred 30 years prior to the date of application

, cost

$1.00.

(non-refundable)

•

SEARCHES

: $.50 for the each year searched

(non-refundable)

Please complete the following information.

FULL

First, Middle and Last Name on Birth Certificate:____________________________________________________________

Has name ever been changed other than marriage ___ No ___ Yes

if so original name ____________________________________

Date of Birth:

Place of Birth (City or County):______________________________

Mother’s

Full Maiden

Name: _________________________________________________________________________________

Father’s Full Name:__________________________________________________________________________________________

Your relationship to the certificate holder :_____________________________________________( self, mother, father etc…)

Reason the Birth Certificate is needed:

# of copies _____________________

Mailing or Delivery Address:

Name: ___________________________________________________Applicant’s Signature______________________________

Address: _________________________________________________________________________________________________

City, State, Zip: _________________________________________________ Daytime Telephone Number: _____________

_____

_________________________________________Notary_

(For use if needed)

___________________________________________

_______

personally appeared before me and whose identity I proved on the basis of satisfactory evidence to be the signer of the

above instrument.

Subscribed and sworn to before me this_______________________ day of _________________ 20____

Signature______________________________________________

Printed Name: _________________________________________

SEAL

Notary Public in and for the State of __________________________

Official

Use Only

Date __________________________________

Rec# __________________________________

Amount ________________________________

Cert #__________________________________

Ser #___________________________________

Residing at _______________My commission Expires____________

NOTICE: STATE LAW PROVIDES PENALTIES FOR PERSONS WHO WILLFULLY AND KNOWINGLY USES OR ATTEMPTS TO

USE OR FURNISH TO ANOTHER FOR USE, FOR ANY PURPOSE OF DECEPTION, ANY CERTIFICATE, RECORD, REPORT, OR

CERTIFIED COPY MADE, ALTERED, AMENDED, OR MUTILATED. (50-15-114(C), MCA)

Comment _______________________________

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