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Here is the text we could read:

 

 
 
 
 
 
 

 
Check your email. You will receive information and 
documents at this email address.  

 am the 

[  ] Petitioner 
[  ] Attorney for the Petitioner and my Utah Bar number is _________ 

In the District Court of Utah 

__________ Judicial District ________________ County 

Court Address ______________________________________________________ 

In the Matter of the Birth of: 

_____________________________________ 
Petitioner 
 

Verified Petition for Order 
Establishing Fact of Birth 

_______________________________ 
Case Number 

_______________________________ 
Judge 
 

Pursuant to Utah Code Section 26-2-9, I ask that the court issue an order establishing 
the fact of my birth as stated below. 

(1) 

I live in ____________________________________________ (county, state). 

(2) 

I was born in _______________________________________ (city, county), Utah. 

(3) 

(4) 

No registered certificate of my birth can be found in the state Office of Vital 
Records and Statistics, the office of any local registrar or any other location. 

I have made the following diligent efforts to obtain the evidence required for a 
delayed birth certificate to be issued by the state Office of Vital Records and 
Statistics: 

Verified Petition for Order Establishing Fact of 
Birth 
 

Approved Board of District Court Judges May 18, 2015 
Revised December 13, 2019 

Page 1 of 3 

 
Name 
 
Address 
 
City, State, Zip 
 
Phone 

 
Email 

  I

 

       

 

(5) 

The state registrar has denied my request to register a delayed certificate of birth 
pursuant to Utah Code Section 26-2-8. A copy of the statement of the state 
registrar is attached. 

(6)  My birth name is _______________________________________ (first, middle and 

last name). 

(7) 

I am [  ]  female  [  ]  male. 

(8) 

I was born on _________________________ (date). 

(9)  My time of birth was _________________________. 

(10)  My birth father’s name is _______________________________________ (first, 

middle and last name). 

(11)  My birth father was born on _________________________ (date) in 

_________________ (state or country). 

(12)  My birth mother’s name is _______________________________________ (first, 

middle, last and maiden name). 

(13)  My birth mother was born on _________________________ (date) in 

_________________ (state or country). 

(14) 

[  ]  I have attached the following documents in support of this petition: 

(15) 

I request a hearing and ask the court to provide notice to the state registrar as 
required by Utah Code Section 26-2-9(4). 

Verified Petition for Order Establishing Fact of 
Birth 
 

Approved Board of District Court Judges May 18, 2015 
Revised December 13, 2019 

Page 2 of 3 

 

 

 

I declare under criminal penalty under the law of Utah that everything stated in this document is true. 

Signed at ______________________________________________________ (city, and state or country). 

Signature ► 

Printed Name 

 

 

 

 
Date 

     

Verified Petition for Order Establishing Fact of 
Birth 
 

Approved Board of District Court Judges May 18, 2015 
Revised December 13, 2019 

Page 3 of 3

Verified Petition for Order Establishing Fact of Birth

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Utah state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from legacy.utcourts.gov (2023-03)
Page(s): 3
Fields(s): 112
Average fields per page: 37
Reading Level: Grade 8
LIST Grouping(s): GO-00-00-00-00.

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Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

Verified Petition for Order Establishing Fact of Birth

About This Form:

Identified Data Fields:

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02