Requested Information Full Name at Birth * date_range access_time Date of Birth * date_range access_time Could this birth be recorded under any other name? * Yes No Example: Adoption If Yes, give full name date_range access_time Mother's Full Name, including Maiden Name * date_range access_time Mother's State of Birth * Please select an option Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Father's Full Name * date_range access_time Father's State of Birth * Please select an option Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Place of Birth * date_range access_time My relationship to the person whose birth record being requested. * date_range access_time Number of Copies Requested * date_range access_time Applicant's Name * date_range access_time Applicant's Address * date_range access_time Address 2 date_range access_time City * date_range access_time State * Please select an option Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip * date_range access_time Applicant's Phone * 111-111-1111 date_range access_time Applicant's Email * date_range access_time Upload Photo ID * File Uploaded Files: Warning: False application, Altering, mutilating or Counterfeiting Indiana Birth Certificates is a Criminal Offense under C.I. 16-37-1-12. navigate_nextContinue Your Session Is About To Expire Click continue to extend your session. Your Session Has Expired Close your browser or click OK to begin a new session.
