Ripley County Health Department
Vital Records Division
P.O. Box 440 Versailles, IN 47042, Phone:  812-689-0508

You must be an immediate  relative of the person listed below to receive a copy of this certificate. 
Please complete all information.  *Applications cannot be faxed back to our office. They must  be mailed back or brought into our office, along with the fee.

WARNING: False application, altering, mutilating, or counterfeiting Indiana birth certificates is a criminal offense under I.C. 16-1-19-6 .

*READ AND FOLLOW THE DIRECTIONS BELOW*

When applying by mail, you must include a SELF ADDRESSED, STAMPED ENVELOPE-Fee $6.00 each certificate-CASH OR MONEY ORDER ONLY- you must also send a photocopy of Driver's License or other ID of  PERSON FILLING OUT THIS APPLICATION.  NO PERSONAL CHECKS ACCEPTED- NO EXCEPTIONS!  IF YOU SEND A PERSONAL CHECK, IT WILL BE RETURNED TO YOU, AND WILL DELAY THE PROCESSING OF YOUR REQUEST.

Application for Birth Certificate

Today's Date:_____/______/______Number of copies requested:____(CERTIFICATES  are $ 6.00 PER COPY)

Full Name at Birth (If female, please put maiden name):_____________________________________________

Date of Birth:____/____/____Place of Birth: City___________________________County________________

Hour of Birth (Optional)_________________________Birth Weight(Optional):__________lbs.____________oz.

Your relationship to this person (If this is your certificate, please put "self") :_____________________________

Father's Full Legal Name:____________________________________________________________________

Mother's Full Legal Name:_____________________________________Maiden Name:__________________

Birthplace of Father (State):________________________Birthplace of Mother (State):___________________

Were mother and father married at time of this birth?  Yes______   No______

Signature of person filling out this application:_____________________________Day time phone#:_____________

Address  of person filling out this   application:_______________________________________________________ _________________________________________________________________________________________________
[FOR OFFICE USE ONLY]:    Book #:__________________Page#:______________Date Filed:_________________ Attendant:____________________________________Occupation:_____________________________________