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IF THE APPLICANT DOES NOT POSSESS A PHOTO ID THEY SHOULD CLICK HERE. PLEASE PRINT VERY CAREFULLY Name Of Registrant At Birth FIRST MIDDLE Date Of Birth LAST Place MM/DD/YYYY CITY/TOWN Father s Name Mother s Maiden Name Purpose For Which Certificate Is Requested NEW HAMPSHIRE LAW REQUIRES THAT A NONREFUNDABLE SEARCH FEE OF 12. 00 BE COLLECTED FOR EACH RECORD REQUESTED. IF THE RECORD IS LOCATED AND YOU MEET ELIGIBILITY REQUIREMENTS YOU WILL BE ISSUED THE REQUESTED NUMBER OF CERTIFIED COPIES OF THAT RECORD. Number and type of certified copies requested please enter quantity of each document Long Form First copy issued at 12. Print Reset APPLICATION FOR CERTIFIED COPY OF BIRTH CERTIFICATE New Hampshire Department of State Division of Vital Records Administration 71 South Fruit Street Concord NH 03301-2410 BIRTH OFFICIAL USE ONLY NUMBER REQUESTED ISSUED PLEASE NOTE A VALID PICTURE ID IS REQUIRED IN ORDER TO PROCESS YOUR REQUEST. A LEGIBLE PHOTOCOPY OF THE APPLICANT S DRIVER S LICENSE OR OTHER GOVERNMENT ISSUED PHOTO ID NEEDS TO BE INCLUDED WITH THIS REQUEST. IF THE APPLICANT DOES NOT POSSESS A PHOTO ID THEY SHOULD CLICK HERE* PLEASE PRINT VERY CAREFULLY Name Of Registrant At Birth FIRST MIDDLE Date Of Birth LAST Place MM/DD/YYYY CITY/TOWN Father s Name Mother s Maiden Name Purpose For Which Certificate Is Requested NEW HAMPSHIRE LAW REQUIRES THAT A NONREFUNDABLE SEARCH FEE OF 12. 00 BE COLLECTED FOR EACH RECORD REQUESTED. IF THE RECORD IS LOCATED AND YOU MEET ELIGIBILITY REQUIREMENTS YOU WILL BE ISSUED THE REQUESTED NUMBER OF CERTIFIED COPIES OF THAT RECORD. Number and type of certified copies requested please enter quantity of each document Long Form First copy issued at 12. 00 each additional copy 8. 00 PLEASE MAKE CHECKS PAYABLE TO Treasurer-State of New Hampshire The certificate s will be mailed to the following address Applicant s Name Address STREET Phone No* STATE ZIP CODE Email AREA CODE NUMBER Signature Relationship Signature is required* NOTICE Any person shall be guilty of a CLASS B Felony if he/she willfully and knowingly makes any false statement in an application for a certified copy of a vital record. Print Reset APPLICATION FOR CERTIFIED COPY OF BIRTH CERTIFICATE New Hampshire Department of State Division of Vital Records Administration 71 South Fruit Street Concord NH 03301-2410 BIRTH OFFICIAL USE ONLY NUMBER REQUESTED ISSUED PLEASE NOTE A VALID PICTURE ID IS REQUIRED IN ORDER TO PROCESS YOUR REQUEST. A LEGIBLE PHOTOCOPY OF THE APPLICANT S DRIVER S LICENSE OR OTHER GOVERNMENT ISSUED PHOTO ID NEEDS TO BE INCLUDED WITH THIS REQUEST. A LEGIBLE PHOTOCOPY OF THE APPLICANT S DRIVER S LICENSE OR OTHER GOVERNMENT ISSUED PHOTO ID NEEDS TO BE INCLUDED WITH THIS REQUEST. IF THE APPLICANT DOES NOT POSSESS A PHOTO ID THEY SHOULD CLICK HERE* PLEASE PRINT VERY CAREFULLY Name Of Registrant At Birth FIRST MIDDLE Date Of Birth LAST Place MM/DD/YYYY CITY/TOWN Father s Name Mother s Maiden Name Purpose For Which Certificate Is Requested NEW HAMPSHIRE LAW REQUIRES THAT A NONREFUNDABLE SEARCH FEE OF 12.

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Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

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  4. Go to the e-autograph tool to put an electronic signature on the template.
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