Birth Certificate &
ID Request Form

Please fill out the form below to the best of your ability. Once you click "SUBMIT", please wait for a confirmation to appear to ensure your application was successfully submitted.

"*" indicates required fields

Date of Application*

Upload Completed State Application*

Max. file size: 50 MB.

Client Name*

First Last

Last 4 Digits of SSN:*

Client Address*

Street Address Address Line 2 City State ZIP Code

Client Email*

Client Phone*

Case Manager Name*

Case Manager Email*

Case Manager Phone Number*

Referring Agency Name*

Referring Agency Address*

Building/Suite #*

Client Gender at Birth*

Client Race*

Client Ethnicity*

Birth Certificate Needed?*

Yes

Florida ID needed?

Yes

Is client homeless?*

Yes

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

What is your reason for needing 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.

Signature of Case Manager*

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.

Birth Certificate & ID Request Form

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

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.

Birth Certificate &
ID Request Form