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.

State of birth

City/Town of birth *

County of birth

Name of hospital

Date of birth

Month *

Day *

Year *

Full name of the person on record

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

First Name *

Middle Name

Last Name *

Suffix

Was the person on record adopted?

No Yes

Please provide the full name after adoption

New first name

New middle name

New last name

Is the person on record now deceased?

No Yes Unknown

Your relationship with person on record

Will this certificate be used for an Apostille?

No Yes

Mother/Parent’s full name

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

First name *

Middle name

Last name *

Father/Parent’s full name

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

First name

Middle name

Last name

Suffix

Contact information

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

First Name *

Middle Name

Last name *

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)

City *

State *

Zip code *

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