CONSULAR VITAL RECORD SEARCH REQUEST FORM
 
THIS FORM MUST BE NOTARIZED AND ACCOMPANIED BY A COPY OF THE APPLICANT'S VALID PHOTO ID.
DATE: ____________   PURPOSE OF REQUEST: ______________________________________________________________________
NAME AT BIRTH DEATH MARRIAGE: ______________________________________________________________________
NAME AFTER ADOPTION (IF APPLICABLE): __________________________________________________________________________
DATE OF BIRTH DEATH MARRIAGE: ______________________________________________________________________
COUNTRY OF BIRTH DEATH MARRIAGE: __________________________________________________________________
FATHER'S NAME: ___________________________________________________________________________________________
DATE & PLACE (STATE/COUNTRY) OF FATHER'S BIRTH: _______________________________________________________
MOTHER'S MAIDEN NAME: __________________________________________________________________________________
DATE & PLACE (STATE/COUNTRY) OF MOTHER'S BIRTH: _______________________________________________________
IF YOU POSSESS A REPORT OF BIRTH/DEATH OR CERTIFICATE OF WITNESS TO
MARRIAGE, PLEASE ENCLOSE A COPY TO AID IN OUR FILE SEARCH.
 
PASSPORT - FIRST ENTRY INTO THE UNITED STATES CURRENT PASSPORT INFORMATION
NAME OF BEARER: ___________________________________ NAME OF BEARER: ___________________________________
DATE OF ISSUANCE: _________________________________ DATE OF ISSUANCE: _________________________________
PASSPORT NUMBER: _________________________________ PASSPORT NUMBER: _________________________________

DATE OF INCLUSION: _________________________________
(IF PASSPORT WAS NOT ISSUED TO THE SUBJECT)		  
 
SIGNATURE: __________________________________________________________________________
                    (SUBJECT, PARENT, OR GUARDIAN)
ADDRESS: ____________________________________________________________________________
DAYTIME TELEPHONE: __________________________________________________________________
 
NOTICE: If you are requesting an amendment or correction to a Consular Report of Birth Abroad, please include certified copies of all documents appropriate for effecting the change (i.e., foreign birth certificate, marriage certificate, court ordered adoption or name change, birth certificates of adopting or legitimating parents, etc.). The original or replacement FS-240, or a notarized affidavit concerning its whereabouts also must be included.
PLEASE INDICATE THE NUMBER OF DOCUMENTS DESIRED
REPORT OF BIRTH (FS-240) ($30.00 ONE REPLACEMENT ONLY): _______
(NOTE: Request for an FS-240 MUST include the original FS-240 or a notarized affidavit attesting to its disposition.)
For the following documents $30.00 for first copy; $20.00 for each additional copy:
  • CERTIFICATION OF BIRTH (DS-1350)................(MULTIPLE COPIES AVAILABLE): ______
  • REPORT OF DEATH...........................................(MULTIPLE COPIES AVAILABLE): ______
  • CERTIFICATE OF WITNESS TO MARRIAGE..........(MULTIPLE COPIES AVAILABLE): ______
  • CERTIFICATION OF NO RECORD........................(MULTIPLE COPIES AVAILABLE): ______
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    RETURN THIS (ORIGINAL) REQUEST FORM TO:
    Passport Services, VitalChek Network, Inc., P O Box 1703, Brentwood, TN 37024-1703