Washington State Department of Health - Vital Records Forms · Washington state form
Authorized Representative Form 422-186
Use this form to authorize someone to request a birth, death, or fetal death certificate on behalf of a qualified applicant. Both signatures must be notarized.
- What this form is
- A qualified applicant uses this form to permit an authorized representative to request a birth, death, or fetal death certificate on their behalf. The qualified applicant and the authorized representative must each sign in the presence of a notary. The representative must submit one complete notarized form with an application for the certificate identified on the form within 60 days of notarization. The form is for one-time use.
- Who needs it
- A qualified applicant who wants another person to request a birth, death, or fetal death certificate on their behalf needs this form.
- Why it needs a notary
- Both the qualified applicant and authorized representative must sign before a notary. Each signature can be notarized online with a commissioned online notary.
- How to submit it
- Submit one complete notarized form with a completed application for the certificate identified on the form within 60 days of notarization. The certificate application may be submitted online, by phone, by mail, or in person.
Questions
Who uses the Authorized Representative Form?
A qualified applicant uses this form to authorize another person to request a birth, death, or fetal death certificate on their behalf.
Do both people need to have their signatures notarized?
Yes. The qualified applicant and the authorized representative must each sign in the presence of a notary. They may use separate notaries, but the Department of Health requires one complete form.
When and how should I submit the form?
Submit one complete notarized form with an application for the certificate identified on the form within 60 days of notarization. The certificate application may be submitted online, by phone, by mail, or in person.