Arkansas Department of Health
Office of Vital Records
BIRTH CERTIFICATE APPLICATION
Only Arkansas births are recorded in this o
ffice. Prior to February 1, 1914, only a limited number of birth records were filed.
Birth
certificates can be requested online, by telephone, by mail, or in-person.
When mailing in this application, include a copy of your photo ID with your payment to the Arkansas Department of Health and mail to the address listed in
the payment section below. Please allow 7-14 days f
or processing.
List Below All Possible Birth Dates and Names Under Which the Certificate May be Registered. (Type or Print)
1. Full Name at Birth
Firs
t
N
ame
Middle Name
Last Name
2. Date of Birth
Month Day Yea
r
Sex Age at Last Birthda
y
3. Place of Birth
City o
r
Town County State
N
ame of Hospital or Street Address
4. Full Name of Father
Firs
t
N
ame Middle
N
ame Last Name
5. Full Maiden Name of Mother
(Name Before Marriage)
First Name Middle Name Last Name
If this child has been adopted, please give original name if known.
If this is a delayed certificate, when was it filed?
What is your relationship to the person whose certificate is being requested?
What is your reason for requesting this certificate?
Is the person whose certificate is being requested still living? Yes
N
o
Signature and contact information of person requesting this certificate.
X
Signature
Contact Number Email Address
• U.S. issued Driver’s License or Identification Card
• U.S. Territories Driver License or Identification Card
• Tribal Identification Card that contains the person’s signature
(note: some cards do not)
• Passport (U.S. or Foreign issued)
• Visa – in passport (and the person’s signature is on the passport,
not the Visa)
• Resident Alien Card (Form 1-551)
• Employment Authorization Card (Form 1-766)
• Employment Authorization Card (Form 1-688A)
• Temporary Resident Card (Form 1-688)
COPIES AND PAYMENT
• 1
st
copy costs $12
• Each additional copy of the same record costs $10
• NOTE: If ADH Vital Records does not find the
birth record requested, the $12 search fee will be
kept as a search charge.
• Payment MUST be submitted with application.
You can obtain a birth record four ways:
Online: Go to ar.gov/vitalrecords. A non-refundable $5.00 processing
fee and a $1.85 identity verification fee will apply in addition to any
expedited shipping options selected. Pay by debit or credit card.
Telephone: Call toll-free at (866) 209-9482. Payment of service fee,
certificate fee, and charges for any expedited shipping options may be
made by debit or credit card (Visa, MasterCard, Discover, or
American Express).
Walk-in: Visit the Vital Records Office at 4815 W, Markham St.
Little Rock, AR 72205. Orders are accepted for same day issuance
from 8:00 am until 4:15 pm, Monday through Friday.
Mail: Include: 1) Application, 2) Copy of photo ID, and 3) check or
money order (DO NOT SEND CASH) payable to:
Arkansas Department of Health
Number of Copies Requested_________
Amount Enclosed $__________
Mail to: Arkansas Department of Health
4815 W. Markham St., Slot
44 Little Rock, AR 72205
Any person who willfully and knowingly makes any false
statement in an application for a certified copy of a vital record
filed in this state is subject to a fine of not more than ten
thousand dollars ($10,000) or imprisoned not more than
five (5) years, or both (Arkansas Statues
20-18-105).
Date
A valid government-issued photo identification card must be provided to
obtain a certificate of birth. The id must contain 1) a photo, 2) current address,
3) signature, and 4) a unique number or barcode (such as driver’s license
number, passport number, etc.) assigned to the person.
A copy of any one of the following forms of photo identification is acceptable:
Please PRINT the name and address of the person
receiving the birth certificate below:
Arkansas
VR-7 (R 11/17)