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.

*READ AND FOLLOW THE DIRECTIONS BELOW*

PLEASE INCLUDE THE FOLLOWING ITEMS WITH YOUR REQUEST:

1. PHOTOCOPY OF DRIVER”S LICENSE OR OTHER I.D. OF PERSON APPLYING FOR CERTIFICATE
2. $10.00 MONEY ORDER OR CASH FOR EACH CERTIFICATE REQUESTED (NO PERSONAL CHECKS)
3. SELF ADDRESSED STAMPED ENVELOPE (ONLY WHEN APPLYING BY MAIL).
4. COMPLETED APPLICATION

IF ANY ITEM FROM THE LIST IS OMITTED YOUR REQUEST WILL BE RETURNED TO YOU.

Today's Date:___________________ Number of copies requested:____(CERTIFICATES  are $ 10.00 PER COPY)

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

Date of Birth: _______________ Place of Birth: (City or town) _________________________________________________

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______

Reason Certificate is needed: Military___ Social Security___ Driver’s License ___work ___Medicaid ___Passport___ Other____

Signature of person filling out this application:________________________________________________________________

Address  of person filling out this   application:_________________________________________________________________

______________________________________________________________________________________________________

(OFFICE USE ONLY):
Book #:____________________________ Page#: __________________FILED:_________________ SEX________________

Attendant:____________________________________________________Occupation:________________________________

WARNING: FALSE APPLICATIONS, ALTERING, MUTILATING, OR COUNTERFEITING INDIANA BIRTH CERTIFICATES IS A CRIMINAL OFFENSE UNDER I.C. 16-1-19-6