[About Divorce Source] Birth Certificate Request* (State Certificate Cost: $25-$35 plus Our Processing Fee: $39.95) Questions? Call 1-800-680-9052 *You MUST complete this form on-line and click the print button on your browser. Submitting the form information via the internet is not an option because we need your signature and a photocopy of the Certificate Holder's Driver's License or State Issued Identification Card. If the Certificate Holder is a child, you must provide a photocopy of a parent's Driver's License or State Issued Identification Card. Step 1. Step 2. Step 3. Complete Form, Print Form and Sign Form Photocopy Driver's License or State ID Fax to 610-770-9342 or Mail to: Certificate Processing Department, Divorce Source, Inc. P.O. Box 1580 Allentown, PA 18105-1580 PROCESSING TIME: Certificate(s) arrive to you within 3-10 business days by Express Courier service and customer signature is required by the courier. Complete, Print & Sign this Form: Certificate Holder's Full Name at Birth: (First - Middle - Last) Sex of Certificate Holder: Choose one... Male Female Certificate Holder's Birth Date: ( MM/DD/YYYY ) Birth State: Birth City: Birth County: Name of Birth Hospital: Is the Certificate Holder Adopted? Choose one... Yes No (If adopted, be sure to use adopted name and adoptive parents names. Pre-adopted certificates are not available.) Mother's Full Name: (First - Middle - Last) Father's Full Name: (First - Middle - Last) Mother's Maiden Name: Purpose of Request: Choose one... Legal Reasons Court Proceedings Identification Passport Travel Use Driver's License Marriage License Welfare Assistance Vetran's Benefits Other Other Reason for Request (if any): Your Name: Yoour Relationship to Certificate Holder: Choose one... Self Mother Father Brother Sister Husband Wife Son Daughter Legal Represenative Mailing Address: (No PO Box, APO, AFO addresses. Street address required!) Mailing City: Mailing State: Mailing Zip: Day Time Phone: E-mail: Credit Card Number: Credt Card Type: Choose one... Visa Master Card American Express Discover Expiration Date: ( MM/YY ) Number of Copies: Choose one... 1 2 3 4 (cost of additional copies vary by state from $5 to $10) Signature Authorization Block... I request a certified copy of the above birth certificate. Signature*: __________________________________ Date: ________________ I authorize Divorce Source, Inc. to process and obtain this birth certificate. I also authorize Divorce Source, Inc. and the appropriate state agency to charge the above credit card for the appropriate amount. I also understand that all sales are final and that delays in processing may occur due to volume and workload of the Department of State. I also acknowledge that the above information is correct and accurate to the best of my knowledge and that the Department of State may contact me for further information regarding this request. *You MUST provide a signature above and attach a photocopy the Certificate Holder's Driver's License or State Issued Identification Card to this form. If the Certificate Holder is a child, you must provide a photocopy of a parent's Driver's License ot State Issued Identification Card. Questions: 1-800-680-9052 Fax Order: 610-770-9342 Mail Order: Divorce Source, Inc - P.O. Box 1580 - Allentown, PA 18105-1580 Processing Time: Certificate(s) arrive to you within 3-10 business days by Express Courier service and customer signature is required by the courier.

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