Indiana Birth Certificate Application Form

Birth information of the person on record

Please complete the birth information below as shown on the birth record. If you are applying on behalf of someone else (i.e. your child), please enter their birth information here.

Date of birth

Full name of the person on record

Please enter Full name at birth of the person on record as shown on the Birth Certificate.

Please provide the full name after adoption

Your relationship with person on record

Mother/Parent’s full name

Please enter the Mother/Parent’s full name.
(If adopted, enter the adopted parent’s full name)

Father/Parent’s full name

Please enter the Father/Parent’s full name.
(If adopted, enter the adopted parent’s full name)

Contact information

Please enter your full name as shown on your ID and your contact information.

Delivery information

Please enter the physical address where you want the certificate to be delivered.
(This address must be the same as the address on the applicant’s identification)