${input_56_5}
${input_56_6_1}

${input_56_6_3} , ${input_56_6_4} ${input_56_6_5}

${input_56_3} :

${input_56_11}
${input_56_13}
${input_56_10}
${input_56_16_1}

${input_56_16_3} , ${input_56_16_4} ${input_56_16_5}

Re: Request for Copy of Birth Certificate

${input_56_14} :

I am writing to request a certified copy of the birth certificate for the following individual:

Gender:

Date of Birth:

${input_56_33}

Place of Birth:

Hospital or Other Location:

${input_56_34}

City:

${input_56_35_3}

County:

${input_56_35_4}

State:

${input_56_35_6}

Father's Name (F, M, L, Suffix):

${input_56_38}

Mother's Name (F, M, L, Suffix):

${input_56_39}

Mother's Maiden Name:

${input_56_40}

Relationship to Party on Certificate:

Reason for Request:

This certificate is being requested for the purpose of

Please mail ${input_56_19} ( ${input_56_20} ) certified of the requested certificate.

Enclosed please find a self-addressed and stamped envelope and a in the amount of ${input_56_48} to cover the cost of the requested . If the enclosed amount is not sufficient, please contact me using the information below or send a bill for the additional cost to the above referenced address.

Should you have any questions or require further information or verification, you may contact me using the information below:

Email: ${input_56_52}

Telephone: ${input_56_53}

Fax: ${input_56_54}

Thank you for your time and assistance in this matter. I look forward to hearing from you.

Sincerely,

___________________________________
${input_56_5}

Enclosure