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City of Northampton, Massachusetts
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Birth Certificate Request Form

  1. INFORMATION OF PERSON ON RECORD
    This section is for information of the person who is listed on this birth record.
  2. Please state how you are related to the person stated above (Examples: Myself, Mother, Father, Guardian, Sibling, Etc.)
  3. INFORMATION OF PARENTS ON RECORD
    This section is for information of the parents who are listed on this record.
  4. REQUESTOR'S CONTACT/MAILING INFORMATION
  5. CONFIRMATION OF REQUESTOR'S IDENTITY
  6. Scan or image of photo identification. We accept State, Federal, or School ID. Selfies are NOT accepted.
  7. By typing your full name above you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
  8. Confirmation of Payment Requirements*
    By checking the box above you are confirming that you understand this request will not be processed until you pay for the records via UNIPAY GOLD which will automatically load once you submit this form.
  9. Leave This Blank: