Kentucky Affidavit of Homeless Status for a Fee Exempt Certified Record of Birth (VS-41)
Official state formOther copy requestsForm VS-41Free downloadLast verified November 10, 2026
Affidavit completed by a homeless services provider to verify that a person is homeless, so the State Registrar can issue a certified Kentucky birth record without a fee. It is mailed to the Office of Vital Statistics in Frankfort with the birth certificate application.
Who can use this form
- The affidavit is completed and signed by a homeless services provider, not by the homeless person.
- Providers include a director or designee of a governmental or nonprofit agency that receives funding to serve homeless people, and a local educational agency liaison, school social worker or school counselor.
- Providers also include a director or designee of a federal TRIO or GEAR UP program, and a financial aid administrator for an institution of higher education.
- The registrant must have been born in Kentucky.
- Each eligible person may receive only one fee exempt birth record per application.
What to send with it
- The completed affidavit, signed by the homeless services provider making the request.
- The printed application for a certified copy of a birth record (VS-37).
- A copy of the requester's agency-issued photo ID or state-issued driver license.
- A copy of the requester's business card or organization-issued name tag, if it does not include a photo.
Where to send it
- Mail to
- Office of Vital Statistics 275 East Main Street 1E-A Frankfort, KY 40621-0001
- State fee
- No fee. The form provides a fee exempt certified birth record under KRS 213.141.
- Typical processing
- Not provided
- Form revision
- Rev. 12.2025
- Source
- Official government page