APPLICATION TO ESTABLISH A DELAYED REGISTRATION OF MICHIGAN BIRTH RECORD
(HOSPITAL USE ONLY)

MAIL APPLICATION WITH PAYMENT TO:
VITAL RECORDS CHANGES
P.O. Box 30721
Lansing, Michigan 48909


PLEASE READ AND FOLLOW INSTRUCTIONS
For additional information: (517) 335-8660, Mon-Fri 8:00 am - 5:00 pm ET

                                               PLEASE PRINT CLEARLY AND LEGIBLY


HOSPITAL REQUESTING DELAYED REGISTRATION       
Please provide hospital name and complete mailing address.

Hospital Name: ______________________________________________________

Hospital Representative: _______________________________________________

Mailing Address: _____________________________________________________

City/State/Zip________________________________________________________

Daytime phone number to contact you: 

Area Code (            ) _______________________________________________

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DELAYED BIRTH RECORD TO BE MAILED TO PERSON OF RECORD OR PARENT NAMED ON RECORD

Name: _____________________________________________________________

Mailing Address: _____________________________________________________

City/State/Zip________________________________________________________

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REQUIRED DOCUMENTATION

Please provide a copy of information contained on the hospital worksheet or medical record to support the establishment of a delayed registration.

Please also include the official statement from the Michigan Department of Community Health that a record of birth is not on file with the State of Michigan.

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INDICATE INFORMATION AS IT SHOULD APPEAR ON THE RECORD


Child's Full Name at Birth:

  _________________     _____________________   ________________________
             First                                      Middle                                           Last

Child's Plurality: _______________________________________________________
                                                   Plurality -Single, Twin, Triplet, etc. (Specify)

Child's Gender:            [   ]  Male        [   ]  Female

Child's Date of Birth: ____________________________________________________
                                                   Month                           Day                  .        Year

Child's Time of Birth: ___________________      [   ]  AM      [    ]  PM
                                                  

Child's Location of Birth: 

___________________________________________________________________
             Hospital                                      City                                    County


Mother's Surname (Before First Married): 

____________________     __________________      ________________________
                 First                                  Middle                                          Last

Mother's Place of Birth: 

___________________________________________________________________
             County                                 State                            or Country, if not U.S.

Mother's Date of Birth: __________________________________________________
                                                   Month                           Day                  .        Year

Father's Full Name: 

____________________     ___________________       ______________________
                 First                                   Middle                                           Last

Father's Place of Birth: 

___________________________________________________________________
             County                               State                             or Country, if not U.S.

Father's Date of Birth: ___________________________________________________
                                                   Month                            Day                  .         Year

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A SIGNATURE IS REQUIRED TO PROCESS THE APPLICATION. 

 	Signature of Person Requesting Delayed Registration: 

___________________________________________	Date:________________

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PAYMENT

The fee for establishing a delayed registration of a Michigan birth record is $30.00 and includes one copy of the record with the changes made. Additional copies of the new record are available for $5.00 each when ordered at the same time.   Payment must be made by check or money order and made payable to the "State of Michigan.".

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PENALTIES:  Any person who willfully and knowingly makes false application to change or amend a Michigan
birth record may be fined not more than $1,000 and/or imprisoned not more than one (1) year.
MCL 333.2894(1)(b) and (c).
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FOR OFFICE USE ONLY - DO NOT WRITE IN THIS AREA

DCH-0845 Rev 06/2001 MCL 333.2827(1) and 333.2891(5)(a)
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END OF THE WRITTEN APPLICATION