Birth Certificate Verification Form

The birth certificate verification form verifies the authenticity of the birth certificate. The verification is based on provision and assessment of the required documents and certificates.

Sample Birth Certificate Verification Form

Name of the child at time of Birth (Full) Last First Middle Names

Sex__Male_____________Female_________________

Date of Birth

City___________________County_________________State_____________________

Full name of Father at the time of child’s birth (First Last Middle)

_______________________________________________________________________

Full name of Mother at the time of child’s birth (Last First Middle & Maiden)

_______________________________________________________________________

Recruiting officer/Representative making request

Name (First Last Middle)                               Rank                         Title

________________________________________________________________________

_________________________

Signature

Corrections on above made according to facts file by

Name (Last First Middle)                                       Organization

Organization Address

Street_____________________City___________________State__________ZIP______

This is to verify that above data as correct are true according to record on file in the office. These data are confidential and cannot be used except for official purpose

Certificate No. ____________File Date (YYYY/MM/DD)

Verified By (Signature)

Office Identification data

Officer/Representative Name (Last First Middle) _______________________________________________________________________________

Unit/Command Name and mailing Address

City_________________County___________________State__________ZIP

Signature                           Dated:  _____ (YYYY/MM/DD)

Category: Verification Forms