3. A five year search of records on file will be made. If no record is found a certification of Not-On-File will be issued and a search fee of $7.00 will be retained.

By Mississippi Statute, a portion ($1.00) of the fee collected for each certified copy is deposited in the Children's Trust Fund administered by the Mississippi Department of Human Services to fund programs to prevent child abuse and neglect.

INSTRUCTIONS

1.  Complete the required sections of this form. PLEASE PRINT.

2.  The application must be signed.

3.  PAYMENT:

Out-of-state:  Remit a bank or postal money order or a bank cashier’s check in the correct amount made payable to Mississippi State Department of Health.

Mississippi Resident:  In addition to the above methods of payment, personal checks are acceptable if drawn on a Mississippi bank; make payable to Mississippi State Department of Health.

We accept no responsibility for cash sent through the mail. Request for adjustments or refunds will be honored only if received within six months of application.

4.  Send completed application, appropriate fee and self-addressed stamped legal size envelope to the address at the top of this form.