180 S. Main St., Ste. 252, Martinsville, IN 46151

765-342-6621, Fax: 765-342-1062 morgancohd@morgancountyhealth.com

Birth Certificate Application-Online

Online: Credit or debit card via the GovPay website:

GovPay Button

***Please note: When paying online, you MUST include a copy of the receipt from GovPay with your application forms.

For Office Use Only (Begin at #1):

Certificate #:
Date:

Morgan County Health Department

180 S. Main St., Ste. 252

Martinsville, IN 46151

´╗┐WARNING: False applications, altering, mutilating or counterfeiting Indiana birth certificates is a criminal offense under IC 16-1-19-6.

For Certificate:


1. Full Name at Birth (First, Middle, Last):*
2. Date of Birth:*
3. Birthplace (County):*
4. Has this person been adopted?*
4a. If yes, has name been legally changed?
4b. If Yes, New Name (First, Middle, Last):
5. Full Name of Father (First, Middle, Last):*
6. Father's State of Birth:
7. Full Maiden Name of Mother (First, Middle, Last):*
8. Mother's State of Birth:

´╗┐For Applicant:

9. Relationship to person on certificate:*
10. Record to be used for:
11. Name of Applicant:*
12. Applicant's Address:*
13. Applicant's Phone:
-
14. Applicant's E-mail:*

By checking the box below, I hereby certify that I am the requestor named above and that I am authorized to request a certified copy of the record for the above named individual, in accordance with Indiana Code 16-37 and 410 Indiana Administrative Code 18. I understand that penalties are described by law for misrepresentation on this request.

15. I agree with the above statement:*

A Birth Certificate set costs $15.00 each (online). This includes one full size and one wallet-size certificate. You may purchase vinyl covers in full size and/or wallet-size for $2.00 each. Please indicate your choices and quantities below.

16. Number of Birth Certificate Sets ($15.00 each):*
16a. Number of Protective Vinyl Sleeves- Full Size ($2.00 each):
16b. Number of Protective Vinyl Sleeves- Wallet Size ($2.00 each):
17. Total Amount ($) Sent (Add amounts from 16+16a+16b):*
18. GovPay Transaction Number:*
19. Upload a File for the receipt from GovPay (jpg, jpeg, png, gif, doc, docx, xls, xlsx- NO PDF Files):*

*** I.D. required. Please provide 1 form of identification. ***

Upload a File for ID (jpg, jpeg, png, gif, doc, docx, xls, xlsx- NO PDF Files):*

If you would like the certificate mailed somewhere other than the above address, please print name and address of the person to whom the certificate is to be mailed:

20. Name:
21. Address:
Word Verification: