Birth Application Form 1c 2016 .pdf

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Title: Microsoft Word - WDH_VSS Birth Application Form 1 2016.docx

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Name as it Appears on the Birth Certificate



A request for a certified copy of a Birth Certificate or
Paternity Form should be submitted on this form along
with the fee of $8.00 per copy. A money order or
personalized check from the person making the request
should be made payable to VITAL STATISTICS


If there is NO birth record on file, you will be sent
instructions for filing a Delayed Birth Certificate, and
your $8.00 fee will be retained as a searching fee.
Enclosed is $______ for ____certified copy/copies
(Indicate how many copies of each)
Legal Birth Certificate(s)
Paternity Form(s) (only if both parents have
signed an affidavit acknowledging paternity)
WARNING Wyoming Statute 35-1-431 states that it
is a criminal violation to, willfully and knowingly, use
or attempt to use a birth certificate for any purpose of



If this certificate could be recorded under another name,
list name here; i.e., an adopted or alias name.
Date of Birth

Sex -



Place of Birth
_________________________________, Wyoming
Mother’s Full Maiden Name (First, Middle, Last)

Full Name of Father or Parent (First, Middle, Last)

Written signature must be a permanent
part of the ID and attached to this

Signature of Applicant
Applicant Address (REQUIRED)

Mail your request with a self-addressed,
stamped envelope to:
Vital Statistics Services
Hathaway Building
Cheyenne, WY 82002
WDH_VSS  Birth  Application  Form  1  2016  

Birth Certificate Checklist
o Are all items complete on the birth certificate application and is the request signed?
o Is a current ID with a signature attached to the request? (i.e., your Driver’s License or
your passport?) If the signature is on the back, provide a copy of both the front and the
o The person that signed the request must provide a copy of their current ID. If the
signature on the application does not match the signature on the ID or if the ID is
expired, the person making the request must have their signature notarized.
o Is the payment of $8.00 provided for each certified copy? We will not accept a 3rd
Party Check [A check from someone other than the person making the request]. If
you do not have a checking account, payment can also be made by money order.
Money orders are available at the Post Office, U.S. Banks and most convenience
stores. Funds must be drawn from a United States bank or credit union.
o Did you include your mother’s maiden name? This is the name your mother had
when she was born. This information will allow us to locate your record more
o Did you include a Self-Addressed-Stamped Envelope (SASE) with your
Requests we receive are often sent back for missing one of the items listed above. When all of
the information is provided, the processing time is greatly reduced. You do not need to send
this checklist in with your request. It is only for your information.
Thank you for your understanding and patience,

Guy Beaudoin
Deputy State Registrar
Vital Statistics Services

WDH_VSS Birth Application Form 1C 2016

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