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RI Department of Children, Youth and Families
Application for a Certified or Non-certified Copy of a Birth Record
 
DCYF Worker – Please complete all questions 1-12
1.
Full Name at Birth
 
     
Date of Birth:
 
     
 
 
 
 
 
 
 
 
2.
Please provide new name if changed in court
 
     
 
 
Place of Birth
 
 
 
3.
City, Town, State, County
 
     
Hospital
 
     
 
 
 
 
 
 
 
 
4.
Mother’s Full Maiden Name
 
     
 
 
 
 
 
 
 
 
5.
Father’s Full Name
 
     
(if listed on record)
 
 
 
 
 
 
 
 
6.
Child’s Current Legal Status:
 
     
CID#
 
     
 
 
 
 
 
 
 
 
7.
Certified copies cost $15.00 for the first copy and $10.00 for additional copies of the same record.
 Non-certified copies cost $0 and $0 for additional copies.  (Costs may vary according to State, Country.)
 
 
 
 
 
 
 
 
 
Full Certified Copy
 
Number Needed
 
     
Non-Certified Copy
 
Number  Needed
 
     
 
 
 
 
 
 
 
 
 
Wallet Size
Number needed
 
     
(This is a laminated card @ $15/copy)
 
 
(Wallet size is not offered in all States; wallet size adds 10 days to DOH processing time of your request.)
 
 
 
 
 
 
 
 
8.
Why do you need this record?  (Department of Health – Vital Statistics ask this question so they can
supply you with a certified copy, which will be suitable for your needs.)
 
 
School
WIC 
Passport
Social Security 
CSE Referral
 
 
License 
Work 
TPR 
Other Specify
 
     
 
 
 
 
 
 
 
 
9.
Requesting DCYF Worker
 
     
 
 
(Requesting worker must sign in the following space for out of state and out of country birth certificate requests only .)
 
 
 
 
 
 
 
 
10.
Region # / Probation
 
        
 
 
 
 
 
 
 
 
 
 
I hereby state that the information supplied above is true to the best of my knowledge, and that the signature
on this application is my own.
 
 
 
 
 
Please Sign
 
Date Signed
 
     
 
 
(Signature of person processing this form in Federal Benefits on behalf of requesting worker –
Voice: 401-528- 3653 Fax: 401-528-3666)
 
 
Please Print Your Name
 
     
 
 
 
 
 
 
 
 
 
Approved  Federal Benefits:
 
Date Signed
 
     
 
 
 
 
 
 
 
 
Address: DCYF   101 Friendship Street (4th floor)          Providence, RI                          02903         
                                        Street or mailing address                City/Town State                     Zip Code
******************************* Below This Line for State Use Only *********************************
State File                  Amount                   Receipt                    Date                             Initials
Number __________ Received __________ Number _________ Sent ____________       ______
Number of first copies               Birth _____                              Death  _____                  Marriage _______
Number of Add’l Copies                       _____                                         _____                               _______
 
Number of Searches ________  Add’l Yrs. Searched _________   Del.      Fil.      Corr.       Pat.       Adop.      Legit.
 
                >>>>>Federal Benefits cannot change request as prepared  by requesting worker <<<<<