ࡱ> psoo <bjbj zzfzff < < 8\)4X&@] Pw%y%y%y%y%y%y%$(N+%u "  %&### Lw%# w%##$+$0١E6!X$c%(&0X&#$,!,+$,+$8 "( #@ T    %%!   X& ,         < G:  Application for a Certified Copy of a Birth Record Please complete ALL items 1-5 below. If you type your information, use the tab key on your keyboard to move to each gray-shaded field. 1. Please fill in the information below for the person whose birth record you are requesting. Full name at birth:  FORMTEXT      Age now:  FORMTEXT      New name if changed in court (excluding marriage):  FORMTEXT      Date of birth:  FORMTEXT      City/town of birth:  FORMTEXT      Hospital:  FORMTEXT      Mother s/parent s full name at birth:  FORMTEXT      Father s/parent s full name at birth:  FORMTEXT       2. I am applying for the birth record of (complete one of the following):  FORMCHECKBOX  myself  FORMCHECKBOX  my child  FORMCHECKBOX  my mother/father  FORMCHECKBOX  my spouse/civil union partner/registered domestic partner  FORMCHECKBOX  my brother/sister  FORMCHECKBOX  my grandchild (parent of mother)  FORMCHECKBOX  my grandchild (parent of father)  FORMCHECKBOX  my clientIm an attorney representing:  FORMTEXT       The name of the law firm is:  FORMTEXT        FORMCHECKBOX  another person (specify your relationship):  FORMTEXT       3. Why do you need this record? (We ask this question so that we can supply you with a certified copy that will be suitable for your needs.)  FORMCHECKBOX  school  FORMCHECKBOX  license  FORMCHECKBOX  Vets benefits  FORMCHECKBOX  Social Security  FORMCHECKBOX  passport/travel  FORMCHECKBOX  foreign govt (specify country of use):  FORMTEXT        FORMCHECKBOX  work  FORMCHECKBOX  WIC  FORMCHECKBOX  welfare  FORMCHECKBOX  other use (specify):  FORMTEXT       4. Walk-In Copies cost $22. Mail-In Copies cost $25. Additional copies of this record purchased the same day cost $18 each. How many copies do you want?  FORMTEXT       (Make check/money order payable to: General Treasurer of RI) 5. 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Please sign ______________________________________________________________ ______________________ signature of person completing this form date signed Type or print your name:  FORMTEXT      Type or print your phone #: (  FORMTEXT     )  FORMTEXT       Type or print your address:  FORMTEXT       (include street or mailing address, city/town, state, and zip code.) ATTACH PHOTOCOPY OF VALID GOVERNMENT ISSUED PICTURE ID From Section 23-3-28 of the General Laws of Rhode Island:  23-3-28 Penalties.  (a) Any person who willfully and knowingly makes any false statement in a report, record, or certificate required to be filed under this chapter, or in an application for an amendment of those, or who willfully and knowingly supplies false information intending that this false information be used in the preparation of any report, record, or certificate, or amendment [& ] shall be punished (if convicted) by a fine of not more than one thousand dollars ($1,000) or imprisoned not more than one (1) year or both.     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