Birth Abroad Worksheet

Note: Fill out form only on a device attached to a printer, as it will be faxed.

Section 1. Birth Certificate Holder Details

Enter the name of the birth certificate holder as it appears on the certificate...

First Name(Required)

First name at birth

Middle(Required)

(or enter "None" or "Unknown")

Last Name(Required)

Last name at birth

Suffix(Required)

(or "none")

Foreign Country of Birth(Required)

City of Birth (if known)

Birth Province (if known)

If exists (and available), an FS-240 no.

Passport Number (if available)

Gender(Required)

Male

Female

Certificate Holder's Birth Date(Required)

Pick: Month / Day / Year

Adopted or Legal Name Change?(Required)

Name change after birth (not marriage)?

First Name (after adoption)(Required)

Middle(Required)

(or enter "None" or "Unknown")

Last name (after adoption)(Required)

Suffix(Required)

(or "none")

Section 2. Parent Information

The Mother's Maiden name and the Father (if known)

IMPORTANT NOTE: To avoid delays, make sure the mother's maiden name is put below.

Next, please enter the birth mother's maiden name...

Mother's First(Required)

Mother's Middle(Required)

(or enter "None" or "Unknown")

Mother Maiden Last Name(Required)

Mother Date of birth(Required)

Pick: Month/Day/Year

Mother's birth country(Required)

Birth State(Required)

And, the Father of Record...

Father's First Name(Required)

Middle(Required)

(or enter "None" or "Unknown")

Father's Last(Required)

Suffix(Required)

(or "none")

Father Date of birth(Required)

Pick: Month/Day/Year

Father's birth country(Required)

Birth State(Required)

Section 3. Contact Information

IMPORTANT NOTE: No PO Boxes. You must list a physical street address below (Also, no APO’s or FPO’s). It must be delivered to where someone can sign for the certificate.

"Ship to" Full Name(Required)

The name that should appear on the envelope with the birth certificate in it

"Ship to" Address(Required)

Physical Address (no PO Boxes)

City(Required)

State(Required)

Zip(Required)

Daytime Phone(Required)

Best number for immediate contact!

Second Phone

The next best number to reach you

Email(Required)

Enter Email Confirm Email

Section 4. Requester Information

That's you, the person making request.

IMPORTANT NOTE: The order can't be processed without your complete name here.

Your First Name(Required)

Middle(Required)

(or "none")

Your Last(Required)

Suffix(Required)

(or "none")

Reason for request(Required)

Other reason(Required)

Section 5. Order Options

No. of copies FS-240 (at $50 each)

Price: $50.00

USBirthcertificate.net expedite service fee	$60
Round trip FedEx Fee (to State Dept. and back to you fast!)	$80

Expedite plus Fedex round trip fee total

Total cost for order

Section 6. Payment Info

Payment Type(Required)

Credit Card Type(Required)

Credit Card Number(Required)

Amex Card Number(Required)

Card Expiration(Required)

Format: mm-yy

CVV Number(Required)

Amex CVV Number

Name on Card(Required)

Exactly as it appears

Note: For your security, you will write your credit card number/expiration only on the printout form that goes into the overnight shipment.

Credit Card billing address is(Required)

Same as shipping address above

Different address

Credit Card Billing Address(Required)

City(Required)

State(Required)

Zip(Required)

Section 7. Verification of info submitted

To help avoid unnecessary delays, please check each item after confirming it to be the case:

This form is the first step. I understand the need to print the resulting pages created after clicking the submit button.

I will be sure to sign the Vital Request Search printed page in front of a notary

The mother's MAIDEN name was used in the last name of the "Mother's Name" field above.

I will include in shipment a clearly readable, zoomed to 200% copy of my valid Driver's License or State ID.

If I am paying by money order or cashier's check, I'll include it in the package, or if paying by credit card, I'll fill it in the printout form.

If I am requesting for my adult child that has no valid ID I have also printed and had the addional form that is required notarized and is included in the package being sent.

I authorize USBirthCertificate.net to expedite my Record of Birth Abroad birth certificate for me. By pressing the submit button below I agree that I have read the order form completely and if the information provided is incorrect, insufficient, or the government agency has no record of the birth that there are no refunds for any reason. I understand that USBirthCertificate.net is a private expediting service and I am hiring you to expedite my Record of Birth Abroad birth certificate order.

We, at USBirthCertificate.net, don't create, change or amend birth records. We only help you retrieve existing records more easily and quickly. ALL SALES ARE FINAL. By clicking the submit button below you will be presented with form results which you'll need to print then ship to our office. By clicking the button below you agree to these terms and the terms above.

To continue the process and prepare a form to be printed, please hit the submit button below.

Yes, I agree to these terms. I'm ready to create my printout to be notarized and mailed.

Once the agreement is confirmed, next click the submit button below. Be sure you get to the form print page (otherwise check form for missing info.)

Name

This field is for validation purposes and should be left unchanged.