Application for a Certified Recognition of Parentage,
Spouse’s Non-parentage Statement or Revocation Form
OFFICE OF VITAL RECORDS
Birth Record Information
First Name
Middle Name
Last Name
Date of Birth
☐Male
Mother/Parent 1
First Name
Middle Name
Maiden Name
Father/Parent 2
First Name
Middle Name
Last Name
Spouse
First Name
Middle Name
Last Name
☐Female
I want a certified copy of:
A certified copy is available to the person who signed or is named on the form, or as authorized by law:
☐ Recognition of Parentage or Declaration of Parentage
☐ Spouse’s Non-parentage Statement or Husband’s Non-paternity Statement
☐ Revocation of a Recognition of Parentage or revocation of a Spouse’s Non-parentage Statement
Requester Information
Name
Mailing Address - Street
Apt/Unit #
Daytime Phone
Email
City
State
ZIP
What is your relationship on the paternity form? You must check one.
☐ I signed the Recognition of Parentage, Declaration of Parentage, Spouse’s Non-parentage Statement, or Revocation form and
my name appears on the form.
☐ I am the child and my name appears on the birth record and the Recognition of Parentage or Declaration of Parentage form.
☐ I am a representative authorized by a person listed above (I am submitting a notarized statement from a person listed above).
☐ I am a representative of the public authority in Minnesota or any other state responsible for child support and have access to the
paternity form for establishing paternity and child support per Minnesota Statutes, section 256.978, subdivision 1a. (I am
including a copy of my employee ID). Birth Record State File Number ________________
Public Authority Agency/County
Public Authority Requester Signature (Notary NOT required)
Signature and Notary Information
I certify that the information provided on this application is accurate and complete to the best of my knowledge.
Requester Signature
Signed or attested before me on:
day of
, 20
Notary Stamp/Seal
Notary Public Signature
My Commission Expires:
PENALTIES: Any person who willfully and knowingly provides false information for a certified vital record may be sentenced up to 1
year in jail or a fine of up to $3000 or both (Minnesota Statutes, section 144.227 and section 609.02, subdivision 3 and 4).
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Application for a Certified Recognition of Parentage,
Spouse’s Non-parentage Statement or Revocation Form
OFFICE OF VITAL RECORDS
Requester Name:
Fee and Payment Information
Number
requested
Item
Certified copy of paternity form sent by First Class Mail®.
Fee
Total
$9 each
Optional: Rush processing fee. This additional fee moves your request ahead of
non-rush requests and applies only to the order in which your request is processed.
Your document will be sent by First Class Mail®.
$20
Optional: Rush shipping fee. Your document will be shipped via United Parcel
Service (UPS) once your document is ready. Your document will be processed as a
non-rush request unless you’ve also chosen the rush processing fee above.
$16
☐ Check here to require a signature for delivery. The Office of Vital Records
and UPS are not responsible for deliveries that do not require a signature.
UPS will not deliver to PO boxes or APO addresses.
Total amount submitted or to be charged to credit card:
(This amount must be at least $9.)
Type of payment:
☐Credit Card
☐Money order
If paying by credit card (MasterCard/VISA/Discover):
Cardholder name
Card number
Expiration date
☐Check
3-digit security code
If paying by check or money order (make payable to Minnesota Department of Health):
Check/money order number
Checks returned for non-payment will be charged a $30 fee according to Minnesota Statutes, section 604.113, subdivision 2 and civil
penalties may be imposed.
The Office of Vital Records will fulfill your request in the order it was received and mail it by First-Class Mail unless
you pay for the optional services listed above.
Send application and payment:
By FAX to 651-201-5740
By EMAIL to [email protected]
By MAIL to:
Minnesota Department of Health
Central Cashiering – Vital Records
PO Box 64499
St. Paul, MN 55164-0499
If you have questions, please contact us at [email protected].
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