MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION BIRTH CERTIFICATE REQUEST FORM

Date:

Children’s Division

P.O. Box 88

Jefferson City, MO 65103

To Whom It May Concern:

I would like to request certified copies of birth certificates on the child(ren) listed on this letter. This form is intended to be used for children born in Missouri only.

Instructions for out-of-state birth certificates can be found here.

The child(ren) is/are a ward of the court in the custody of our agency.

This information is needed for official Children's Division business purposes of pursuing (TPR) Termination of Parental Rights in order to free the child(ren) for adoption.

Other Reasons: Death Modification

Please mail one certified copy of each birth certificate to:

County/Agency:
Designee:
Email Address:
Mailing Address:

Sincerely,

Designee

Please save request form using the following file-naming convention:

County or Agency name+Last name of first child on form+Date sent

Example: ColeCoEdwards4-27-17

Please email all request forms to CD.BCRequests@dss.mo.gov

Must be an active AC case in FACES Mother’s MAIDEN name must be used Everything must match IBTH in PROD Fields marked with an (*) are required; the request cannot be processed if required fields are blank. Please review for accuracy, including correct spelling of all names to prevent processing delays.

Child's Name (*First, *Middle, *Last)
*Child’s DCN:	*Date of Birth	*Sex
Hospital	City	County	State MO
Father's Name (*First, *Middle, *Last) Father Unknown
Mother's Name (*First, *Middle, *Maiden)

Child's Name (*First, *Middle, *Last)
*Child’s DCN:	*Date of Birth	*Sex
Hospital	City	County	State MO
Father's Name (*First, *Middle, *Last) Father Unknown
Mother's Name (*First, *Middle, *Maiden)

Child's Name (*First, *Middle, *Last)
*Child’s DCN:	*Date of Birth	*Sex
Hospital	City	County	State MO
Father's Name (*First, *Middle, *Last) Father Unknown
Mother's Name (*First, *Middle, *Maiden)

Child's Name (*First, *Middle, *Last)
*Child’s DCN:	*Date of Birth	*Sex
Hospital	City	County	State MO
Father's Name (*First, *Middle, *Last) Father Unknown
Mother's Name (*First, *Middle, *Maiden)

Child's Name (*First, *Middle, *Last)
*Child’s DCN:	*Date of Birth	*Sex
Hospital	City	County	State MO
Father's Name (*First, *Middle, *Last) Father Unknown
Mother's Name (*First, *Middle, *Maiden)