Civil Union Certificate Order Form

Civil Union certificates are available from the Department of Health only for civil unions which occurred within the past five years. After five years, the records are transferred to the Division of Public Records.

• How to order Vital Records from the Division of Public Records

To order a civil union certificate from the Department of Health:

• Complete the application below
• Print it on your local printer.
• Sign and date the application
• Return it with your check or money order to the address below.
  Make checks or money orders payable to: Vermont Department of Health. Do NOT mail cash.

Send to:
Vermont Department of Health
Vital Records
P.O. Box 70
Burlington, VT 05402-0070

Fees:
Certified copy: $10.00
Verification: no charge
Record Search: no charge

For more information visit: Obtaining Vital Records Home

Application for Vital Record Certificate of Civil Union

For office use only ID# CPA# REC#

Request for:

Certified Copy Verification Record Search

Date of Civil Union
Town of Civil Union :

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PARTY A Name :
Date of Birth:
Name of Father:
Name of Mother:

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PARTY B Name:
Date of Birth:
Name of Father:
Name of Mother:

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Your Name :
Address:
Town:
State:
Zip:
Phone Number:
Your Relationship to couple on civil union certificate

Intended use of certificate

Proof of Civil Union Family History Other: (specify)

Date: _____________________________

Signature: _____________________________________________________________________

Send to: Vermont Department of Health, Vital Records, PO Box 70, Burlington, VT 05402-0070