Missouri Fee Exempt Birth Certificate Form for Victims of Domestic Violence or Abuse (MO 580-3430 (VS-173))
Official state formOther copy requestsForm MO 580-3430 (VS-173)Free downloadLast verified November 10, 2026
Fee waiver form that gives a victim of domestic violence or abuse one fee-exempt certified copy of a birth certificate. It is sent with the vital record application to the Bureau of Vital Records and can also be used at a local public health agency.
Who can use this form
- A victim of domestic violence or abuse as defined in section 455.010 RSMo
- The waiver can be used one time
- Section I is signed by an employee, agent or volunteer of a victim service provider, an attorney, or a health care or mental health professional
What to send with it
- This form, with Section I signed under penalty of perjury
- The Application for Missouri Vital Record, meeting all other requirements
Where to send it
- Mail to
- DHSS - Bureau of Vital Records 930 Wildwood Dr. Jefferson City, MO 65109
- State fee
- No fee for one certified copy under section 193.265 RSMo. The statutory fee applies to additional copies.
- Typical processing
- Not provided
- Form revision
- 8-2023
- Source
- Official government page