Arkansas Vital Records Authorization Form
Official state formOther requestsFree downloadLast verified November 10, 2026
Lets a person who is already eligible for an Arkansas birth, death, marriage or divorce record name another person (the designee) to receive the certificate for them. The designee brings it to Arkansas Department of Health Vital Records in person, or it is faxed to the office.
Who can use this form
- A person who is already eligible to receive the vital record fills out and signs the form.
- The designee named on the form receives the certificate.
- The authorization is valid only for the single date written on the form.
What to send with it
- The signed authorization form.
- A copy of the eligible person's acceptable identification.
- The designee's own acceptable identification, shown to receive the certificate.
- The form and ID copy may be submitted in person by the designee or by fax to (501) 661-2337.
Where to send it
- Mail to
- See the form for where to file it.
- State fee
- Not provided
- Typical processing
- Not provided
- Form revision
- Revised 02/17
- Source
- Official government page