Center for Health Statistics
P.O. Box 9709
Olympia, WA 98507
360-236-4300
To request this document in another format, call 1-800-525-0127.
Deaf or hard of hearing customers, please call 711 (Washington Relay) or email civil.rights@doh.wa.gov
DOH 422-182 July 2021
Instructions for Birth Certificate Order Form
Carefully read these instructions before completing and submitting the Birth Certificate Order Form. Chapter 70.58A RCW and
Chapter 246-491 WAC requires all applicants to be a qualified applicant, provide identity and proof of eligibility documentation, and
provide required information to order a birth certificate.
Checklist for completing the Birth Certificate Order Form:
Complete all fields on the birth certificate order form, sign, and date
A copy of your identity document(s)
A copy of your proof of eligibility document(s)
Check or money order made payable to DOH (certificate purchases are nonrefundable)
Send the order form, all documents, and payment to:
Department of Health
Center for Health Statistics
PO Box 9709
Olympia, WA 98507
If submitting the order form with a correction request, send all
documents and payment to:
Center for Health Statistics
Attn: Corrections
PO Box 47814
Olympia, WA 98504-7814
What is a qualified applicant?
A qualified applicant is a person who is eligible to receive a certificate.
Who are the qualified applicants for a birth certificate?
Qualified applicants for a birth certificate are: Self, Spouse/Domestic Partner, Child, Parent, Stepparent, Stepchild, Sibling,
Grandparent, Grandchild, Great Grandparent, Legal Guardian, Legal Representative, Authorized Representative, or Government
Agency or the Courts (only for official duties).
Are you one of the qualified applicants listed above to the birth certificate you are requesting?
If yes, continue. You will need to provide identity and proof of eligibility documentation.
**If you are not one of the listed above, STOP. You will not receive a WA State birth certificate**
What is proof of eligibility documentation?
Proof of eligibility documentation are documents that link you to the requested birth certificate.
1. If you are listed on the record and your identity documentation sufficiently links you to the record (i.e. self or parents), your
proof of eligibility requirement is met.
2. If you are not listed on the record or your identity documentation doesn’t sufficiently link you to the record, you must
provide additional documentation to prove eligibility.
What documents will the Department of Health (DOH) accept to prove eligibility?
DOH will accept the following documents to prove eligibility:
• Copies of vital records such as certifications of birth, death, marriage, and divorce from this or another jurisdiction that link
you to the requested record
• Copies of certified court orders from a court of competent jurisdiction linking you to the record (i.e. legal guardian)
• Document or letter from a government agency or courts stating the certification will be used in the conduct of official
duties (for government and court officials only)
View the Proof of Eligibility (PDF)
for examples of how to prove qualifying relationship.
Center for Health Statistics
P.O. Box 9709
Olympia, WA 98507
360
-236-4300
To request this document in another format, call 1-800-525-0127.
Deaf or hard of hearing customers, please call 711 (Washington Relay) or email civil.rights@doh.wa.gov
DOH 422-182 July 2021
What identity documentation will DOH accept?
DOH will accept a copy of:
• One government issued identity document (must contain photo, full name, and date of birth) that is current or expired less
than 60 days; or
• If you do not have a government issued identity document, then at least two alternate documents from the alternate list.
The alternate documents must contain matching first and last names and addresses, or in combination contains full name,
date of birth, and photograph.
View the list of acceptable identity documentation.
What information is required?
The following information is required as it appears on the birth certificate:
• First, middle, and last name of the subject of the record
• First and last name of all parents listed on the record
• Date of birth (month, date, year)
• City or county where the birth occurred
What if I cannot provide the required documents to prove eligibility, do not have identity documents from the acceptable list, or
know the required information?
If you are unable to meet the requirements, you may submit a request for an exception. This process allows the applicant to explain
why you are unable to provide the required documentation or information.
What is an Heirloom birth certificate?
The Heirloom birth certificate is a birth certificate signed by the Governor and the State Registrar. For more information on
Heirlooms, please visit
Ordering a Birth Record :: Washington State Department of Health.
What address do I put on the order form?
The address you provide on the order form must be the address you are REGISTERED to receive mail at. If that is not an option, put
the name of the individual registered at the address and then put “in care of” before your name (Ex. John Doe C/O Jane Doe, 101
Israel Rd SE, Tumwater, WA 98502). If filling in the form by hand, please print clearly to avoid delay in processing.
What form of payment is accepted?
We accept checks or money orders for requests mailed to DOH. Make sure your check or money order is made payable to DOH.
Important note: no refunds will be given if a record could not be located or the documentation you provided did not prove you
were eligible to receive a birth certificate.
Helpful tip: To confirm DOH received your order over the phone, we need:
• For Checks: Check number, date it was cashed (check with your banking institution before calling DOH), and name on the
check
• For Money Orders: Money order number and date it was cashed (to find this date call the number provided on your money
order receipt)
For more information about vital records, please visit our website at https://www.doh.wa.gov/vitalrecords
.
To request this document in another format, call 1-800-525-0127.
Deaf or hard of hearing customers, please call 711 (Washington Relay) or email civil.[email protected]a.gov
DOH 422-182 JULY 2021
BIRTH CERTIFICATE
MAIL ORDER FORM
REGISTER
VALIDATION SPOT
MAIL ORDERS TO:
Department of Health
PO BOX 9709
OLYMPIA WA 98507-9709
DO NOT USE ANY UNAPPROVED THIRD-PARTY VENDOR TO
OBTAIN THIS FORM. DO NOT PAY A FEE FOR THIS FORM
MAKE CHECKS & MONEY ORDERS
PAYABLE TO: DOH
NO REFUNDS
☐
I have included a copy of my identity document(s), my proof of eligibility document(s), and the required nonrefundable fee.
See instructions for more information.
☐
By signing this form, I declare under penalty of perjury under the laws of the state of Washington that the information I have provided
is true and correct. Further, be advised that willfully providing a false statement to vital records for a certificate is a gross
misdemeanor under Washington law, RCW 70.58A.590(2).
SIGNATURE (APPLICANT) DATE SIGNED: (MM/DD/YYYY)
FEES: (Check the box to select order type then enter the quantity.)
☐
Total number of CERTIFIED certificates
x
$25
=
☐
Total number of
HEIRLOOM
certificates
x $50 =
☐ APOSTILLE:
(Indicate country requesting document here)
x $15 =
SHIPPING: (expedited shipping does NOT mean expedited processing)
☐ First Class Mail: (No additional charge)
$0 =
☐
*USPS Express Mail Delivery: (street address or PO Box)
$26.35 =
☐
**FedEx to continental US: (no PO Box)
$15
=
☐ FedEx to AK/HI/Canada/Mexico:
(no PO Box)
$25 =
TOTAL AMOUNT DUE:
(ADD THE FEE AMOUNT(s) + SHIPPING FOR TOTAL DUE)
FOR OFFICE USE ONLY
APOSTILLE
☐
VERIFIED
DATE: INITIALS:
☐
SENT TO SOS
DATE: INITIALS:
☐
NOTATED IN WHALES
FEE#
COUNTRY:
APPLICANT INFORMATION
NAME OF PERSON/COMPANY ORDERING CERTIFICATE (S):
ADDRESS SENDING CERTIFICATE (S) TO: (STREET ADDRESS REQUIRED FOR FEDEX ORDERS)
CITY:
STATE:
ZIP CODE:
COUNTRY:
DAYTIME TELEPHONE NUMBER:
EMAIL ADDRESS:
To receive a birth certificate, you must indicate your relationship to the registrant below and sign the sworn statement that you are authorized to
receive the certificate.
SELECT
RELATIONSHIP:
☐ SELF ☐ PARENT ☐ SIBLING ☐ GREATGRANDPARENT ☐ AUTHORIZED REPRESENTATIVE
☐
SPOUSE/DOMESTIC
PARTNER
☐ STEPPARENT ☐ GRANDPARENT ☐ LEGAL GUARDIAN ☐ GOVERNMENT AGENCY
☐
CHILD
☐
STEPCHILD
☐
GRANDCHILD
☐
LEGAL REPRESENTATIVE
☐
COURTS
All the following fields must be completed to process the order.
BIRTH RECORD DETAILS
CERTIFICATE HOLDER FIRST NAME(S):
CERTIFICATE HOLDER FULL MIDDLE NAME(S):
CERTIFICATE HOLDER LAST NAME(S):
DATE OF BIRTH:
CITY OF BIRTH:
COUNTY OF BIRTH:
COUNTRY OF BIRTH:
PARENT/MOTHER FIRST NAME(S):
PARENT/MOTHER MIDDLE NAME(S):
PARENT/MOTHER LAST NAME(S): (PRIOR TO FIRST MARRIAGE)
PARENT/FATHER FIRST NAME(S):
PARENT/FATHER MIDDLE NAME(S):
PARENT/FATHER LAST NAME(S):
