Birth Certificate Worksheet Form

Section: Birth Parent's Information

Birth Parent's Name (Birth Mother's Name)

Nombre

Apellido

Birth Parent's Maiden Name (Last Name Given at Birth - Please enter even if same as current legal last name)

Birth Parent's Date of Birth (Birthing Mother)

Birth Parent's City and State of Birth (Country if not USA)

Birth Parent's Legal State of Residence (Country if not USA)

Birth Parent's County of Residence (Territory or Providence if not USA)

Birth Parent's Locality - Call your city/town/village clerk's office at your city/town/village hall for this. Please do not guess. When you call, confirm you have the right hall by giving them your address.

If City or Village, Is Residence within City or Village Limits? If No, specify town in fill-in box, e.g. Town of _____. Please call your city/village/town clerk's office for the answer to this question. Do not guess as these boundaries can change.

Yes, within limits No, outside limits

Birth Parent's Residence Address

Dirección

Ciudad

Estado / Provincia

Código postal

Birth Parent's Mailing Address

Dirección

Ciudad

Estado / Provincia

Código postal

Is Medicaid a Secondary Payor for you Birth (secondary to other insurance you have)

Yes

Are you Enrolled in an HMO through your insurance

Yes

Birth Parent's Education Level

Less than High School High School Graduate Some College Bachelor's Degree Graduate Degree

Birth Parent's Latinx/Hispanic/Spanish Origins

Yes No

Birth Parent's Race (check as many as apply - the terminology is taken directly from the Birth Certificate form - if you prefer a different description, you may enter that in other)

Was Birth Parent Employed During this Pregnancy

Yes No

Birth Parent's Current/Most Recent Occupation (If you have been a stay at home parent without paid work, you may enter that here)

Birth Parent's Kind of Business or Industry, if not stay at home parent

Birth Parent's Name of Firm, if self-employed, you may write that if you don't have an entity

Birth Parent's Address of Firm, if self-employed and work from home, you may enter your home address

Dirección

Ciudad

Estado / Provincia

Código postal

Baby's Name (You may have more than one middle name and more than one last name. If you want a hyphenated last name, please include the hyphen.)

Nombre

Apellido

Baby's Date of Birth

Locality of Birth if Different than Residence Locality (If you gave birth at a different residence than the one you listed above, please call the clerk's office for the residence where you gave birth to request the Locality for the Birth Location.)

County of Birth if Different than Residence

Is Birth Parent Legally Married? (Please note, by NY Law, no 2nd Parent can be listed on Birth Certificate if

Yes No

Section: Second Parent's Information

Second Parent's Name (Legal Spouse or, if not married, Father of Baby if Acknowledgement of Paternity will be Signed. New York only allows a Second Mother on Birth Certificate if couple is legally married.)

Nombre

Apellido

Second Parent's Date of Birth

Second Parent's City and State of Birth (Country if not USA)

Second Parent's/ Spouse's Education Level

Less than High School High School Graduate Some College Bachelor's Degree Graduate Degree

Second Parent's Latinx/Hispanic/Spanish Origins

Yes No

Second Parent's Race (check as many as apply - the terminology is taken directly from the Birth Certificate form - if you prefer a different description, you may enter that in other)

Second Parent's Current/Most Recent Occupation (If you have been a stay at home parent without paid work, you may enter that here)

Second Parent's Kind of Business or Industry

Second Parent's Name of Firm

Second Parent's Address of Firm

Dirección

Ciudad

Estado / Provincia

Código postal

Certification statement

Birth Certificate Worksheet Form

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