The 522 Mississippi form is an application used to request a certified copy of a birth certificate from the Mississippi State Department of Health. This form is essential for individuals who need to obtain their birth records for various purposes, such as legal identification or personal matters. To ensure a smooth application process, make sure to fill it out completely and provide the necessary identification.
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The 522 Mississippi form is an essential document for anyone seeking a certified copy of a birth certificate from the Mississippi State Department of Health. This application requires the full name of the individual as it appears on the birth record, along with details such as the date and place of birth, and the names of the parents. It also asks whether the individual has had a name change since birth. Applicants must indicate their relationship to the person named on the certificate and provide a valid form of photo identification. A non-refundable search fee of $15.00 is required, which covers the cost of searching for the record and entitles the applicant to one certified copy if found. If additional copies are needed, they can be ordered at a reduced rate. The form emphasizes that only individuals with a legitimate interest, such as the registrant or close relatives, may request a certified copy, ensuring the privacy and security of personal information. Furthermore, applicants must be aware that failure to provide proper identification will result in the application being returned unprocessed. With clear instructions and a straightforward process, the 522 Mississippi form serves as a vital tool for obtaining important personal records.
When filling out the 522 Mississippi form for a certified birth certificate, applicants often make several common mistakes that can lead to delays or rejections. One frequent error is not providing a complete and accurate full name. The form requires the full name as it appears on the birth record, including any changes. Omitting any part of the name can result in complications during processing.
Another mistake involves the failure to indicate whether the applicant has had a name change since birth. If applicable, the original name must be provided. Not disclosing this information can lead to confusion and additional inquiries from the Vital Records office.
Applicants sometimes neglect to include the required payment. The application specifies a non-refundable search fee of $15.00, which must accompany the form. Without this payment, the application will not be processed. Additionally, applicants should ensure that they do not send cash, as this is explicitly prohibited.
Providing insufficient identification is another common issue. The form states that a valid photo ID is necessary for processing. Acceptable forms include a driver's license or passport. Failure to include this identification will result in the application being returned unprocessed.
Another mistake is not clearly stating the relationship to the applicant. This information is crucial for verifying eligibility to obtain the birth certificate. The applicant should clearly identify their relationship, whether they are the registrant, a parent, or another eligible family member.
Lastly, applicants often overlook the mailing address section. It is vital to provide a complete and accurate delivery address, including any apartment numbers. If the address is incorrect, it can delay the receipt of the birth certificate or result in it being returned to the Vital Records office.
APPLICATION FOR CERTIFIED MISSISSIPPI BIRTH CERTIFICATE
Mississippi State Department of Health
Vital Records
Post Office Box 1700, Jackson, Mississippi 39215-1700
FULL NAME ON
FIRST
MIDDLE
LAST
BIRTH RECORD
HAS NAME CHANGED
If so, what was original name?
SINCE BIRTH?
□ Yes
□
No
DATE OF
MONTH
DAY
YEAR
STATE FILE NUMBER IF KNOWN
BIRTH
PLACE OF
COUNTY
CITY
STATE
SEX
RACE
MALE
□ FEMALE
FULL MAIDEN
NAME OF MOTHER
FULL NAME
OF FATHER
PERSON REQUESTING CERTIFIED COPY
RELATIONSHIP TO APPLICANT
PURPOSE FOR WHICH NEEDED
SIGNATURE OF APPLICANT
DATE
A BIRTH RECORD SEARCH REQUIRES ADVANCE PAYMENT OF A NON REFUNDABLE SEARCH FEE OF $15.00 AND VALID PHOTO IDENTIFICATION.
The $15.00 fee entitles the applicant to one Certified copy of the birth record on file of if the record is not found a “Not on File” statement will be issued. Surrounding counties and five years centered on year of birth are searched if record is not located within county or year specified.
$ 15.00
X
1
=
$15.00
Additional Certified copies of the same record ordered at the same. $5.00 for each additional certified copy.
TOTAL AMOUNT ENCLOSED. Check or Money Order payable to Mississippi Vital Records. Mississippi law allows an additional Service charge for dishonored checks. (DO NOT SEND CASH)
$ 5.00
Amt.
No. of copies
Enclosed
TOTALS
PHOTO IDENTIFICATION REQUIRED
Failure to provide the proper identification will result in the application being returned to you without processing. Acceptable forms of identification are: Valid Driver’s License, State Issued Identification Card, Passport, and/or Military Identification Card, Valid School, College or University Identifications. (See back for other acceptable forms).
APPLICANT NAME/DELIVERY INFORMATION
Pursuant to Section 41-57-2 of the Mississippi Code of 1972, Annotated and as defined by Mississippi State Board of Health Rules and Regulations only person having legitimate and tangible interest in a birth certificate is entitled to obtain a copy. Anyone obtaining a copy of a birth certificate under false pretenses is subject to the penalties as described in Section 41-57-27 of the Mississippi Code.
PRINT YOUR MAILING ADDRESS HERE
Applicant Name (Type or Print)
Delivery Address (include apt number)
City
State
ZIP Code
Phone Number, including area code
DO NOT WRITE IN THE SPACES BELOW – FOR OFFICE USE ONLY
12
–36
S.C.
SUP.
37
– 66
P.
C.D.
CWA.
Revised 3-18-11
Form 522
INFORMATION AND INSTRUCTIONS FOR BIRTH RECORD APPLICATION
Eligibility:
A certified copy of a birth certificate can be issued only to a person with legitimate and tangible
interest as defined by the Rules Governing the Registration and Certification of Vital Events.
Primarily this is:
1)
Registrant (the child named on the record), if of legal age.
2)
Parent(s) listed on the birth record, if VR office has not been notified of termination of parental rights.
3)
Spouse, sibling(s), or grandparent(s)/child(ren) of registrant, proof of relationship required.
4)
Legal Guardian, guardianship papers must be provided.
5)
Legal representative of one of the above persons, proof of representation must be provided.
6)
Licensed adoption agencies working within the statutory authority of §93-17-205.
7)
Other person(s) by court order, certified copy of court order must be provided.
Birth records are available for genealogy purposes for birth events occurring over 100 years ago. Genealogy must be provided as purpose for certificate and family relationship to the registrant must be specified. Plain paper copies rather than certified copies are provided for genealogy purposes.
Requirements for Ordering: If applicant is self, spouse, parent, grandparent, sibling, child, grandchild, guardian, or legal representative, then the applicant must provide a completed application and a copy of a valid photo identification of the applicant. Acceptable forms of identification are the following:
■ Photo Driver’s License
■ Photo State Issued ID
■ Employment ID
■ School, College or University ID
■ US Military ID
■ Tribal ID
■ Alien Registration/Permanent Resident Card
■ Temporary Resident Card
■ US Passport
OR two forms of identification from the following list:
■ Social Security Card
■ Utility Bill (showing address)
■ Medicaid Card
■ Snap/EBT card (showing address)
■ Work Identification
■ Veteran Universal Access ID Card
Guardian or legal representative must submit proof of guardianship/legal representation with this application. Legal representatives must provide attorney bar number, name of person represented, and their relationship to the registrant. If you are an agent of local, state or federal agency requesting a record, indicate in the space provided for “relationship” the name of the agency. If you do not have one of the above referenced documents, please contact Vital Records at 601-576-7981.
Relationship to Applicant: A person ordering his or her own certificate should enter “SELF” in this space. Also, explain if name has been changed by marriage, legal name change (when and where), etc. Others must identify their relationship to the registrant clearly.
Nonrefundable: Vital record fees are nonrefundable, with the exception of fees paid for additional copies when no record is found.
Failure to Receive: Complaints of failure to receive certified records will be honored within 6 months of the original request. If the copy was to be returned to you by U.S. Postal Service, please allow 3 weeks after mailing the request before inquiring. Inquiry about copies ordered with payment for special courier delivery should be made within 7 days of the request. Mail returned because of insufficient address or address changes will be re-mailed if this office is notified of correct address within 6 months of request.
Options for Service: Certified copies of birth records may be ordered in person, by mail, or, if paying by credit card, online or by telephone. Processing time is generally 7 – 10 working days after receipt of request. If amendment action is necessary, additional processing time will be required. Payment of fees is required at the time of ordering.
•WALK-IN SERVICE is available at 571 Stadium Drive, Jackson, Mississippi between the hours of 8:00 am and 5:00 pm. Most records will be available while you wait, some require special processing and will be mailed within 7 - 10 days of the request.
•MAIL-IN requests, either on the form provided or as a free form request will be processed in the order received and will be returned by regular U.S. Postal Service, unless accompanied by a prepaid special courier self-addressed envelope.
•PAYMENT BY CREDIT CARD can be done using an online service or by telephone. The private company approved to handle credit card transactions for Mississippi birth records can be accessed by calling 601-576-7988 or by visiting www.msdh.state.ms.us/phs and clicking on link for online ordering. If you have questions or need additional assistance call 601-576-7981. A recorded message outlining ordering requirements and options can be accessed by dialing 601-576-7450.
MAIL THIS APPLICATION WITH PAYMENT AND COPY OF IDENTIFICATION TO:
MISSISSIPPI VITAL RECORDS
P.O. BOX 1700
JACKSON, MS 39215-1700
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