SCS Birth Certificate & ID Request Form

Please take a moment to fill out the form.
NOTE: ALL FIELDS MUST BE COMPLETED.

Date of Appliation:

Client Name

Last 4 of SSN

Client Address

Client Email

Client Phone #

Name of Case Manager

Case Manager's Email

Case Manager Phone #

Referring Agency Name

Referring Agency Address

Building/Suite #

Birth Certificate Information

Birth Certificate Needed?

Yes

If Yes, Client's Date of Birth

City/State of Client's Birth

Make Check Payable To (see instructions on the State's Application)

Exact Amount of Check ($) (see instructions on the State's Application)

Florida ID Information

Florida ID Needed?

Yes

If Yes, Client's Date of Birth

Is client homeless?

Yes

We can supply Birth Certificates and/or IDs only if needed for one of the reasons below

Reason for ID:

Employment

Vocational Training

Please note: Regarding the FL ID, if client is homeless, the client may go to the DMV with a letter or affidavit from your agency confirming their homeless status. Second Chance Society endorses this approach in order to meet client needs.

I, the Case Manager, have referred the client above to Second Chance Society for their assistance. I acknowledge that the client has authorized me and my agency to periodically release information to Second Chance Society regarding the client’s birth certificate and/or ID needs for a period of up to one year from the date of award any goods or services from Second Chance Society to the client.

Signature of Case Manager:

Once you click "SUBMIT", please wait for a confirmation to appear to ensure your application was successfully submitted.

SCS Birth Certificate & ID Request Form

Birth Certificate Information

Florida ID Information

*We can supply Birth Certificates and/or IDs only if needed for one of the reasons below*

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We can supply Birth Certificates and/or IDs only if needed for one of the reasons below