The authorized representative form, Form 422-186, is a notarized document from the Washington State Department of Health (DOH) Vital Records that lets a qualified applicant permit another person to request a birth, death, or fetal death certificate on their behalf. It is for people who are eligible to receive a certificate but want someone else to make the request. On this page you can fill out the form online on FillingPDF and download or print the completed PDF; both parties then sign before a notary, and DOH publishes the official PDF and instructions at doh.wa.gov.
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What is 422-186?
The Authorized Representative Form (DOH 422-186) is a legal document issued by the Washington State Department of Health that allows an individual to become an authorized representative and request a birth, death, or fetal death certificate on behalf of a qualified applicant.
DOH defines an authorized representative as a person permitted to receive a certificate who is either identified in a notarized form signed by a qualified applicant, or an agent identified in a power of attorney. This form is the first route. A qualified applicant is a person who is eligible to receive the certificate.
Completing the form produces a notarized permission. In the printed declaration the qualified applicant grants permission to the named individual, states under penalty of perjury under Washington law that the information is true and that they are a qualified applicant as listed in RCW 70.58A.530, and acknowledges that willfully providing a false statement to vital records for a certificate is a gross misdemeanor under RCW 70.58A.590 (2).
The form is not the certificate application. When the authorized representative orders the certificate, the notarized form serves as the eligibility documentation that proves the qualifying relationship; the application, identity documents and fees are separate. DOH also lists Spanish-language instructions for this form (Instrucciones para el Formulario de representante autorizado) among its vital records forms.
Who needs to file 422-186?
A qualified applicant who wants another person to request a birth, death, or fetal death certificate for them completes this form together with that person, who becomes the authorized representative. Both must read the instructions before completing and notarizing it.
The DOH instructions list who counts as a qualified applicant for each record type:
- Birth certificates: self, spouse/domestic partner, child/stepchild, parent/stepparent, sibling, grandparent, grandchild, great grandparent, great grandchild, legal guardian, legal representative, and a government agency or the courts (only for official duties).
- Long form death certificate: spouse/domestic partner, child/stepchild, parent/stepparent, sibling, grandparent, grandchild, great grandparent, great grandchild, legal guardian, legal representative, next of kin (if no one else from the list is living), a funeral home listed on the record (within 12 months of date of death), and a government agency or the courts (only for official duties).
- Short form death certificate: the same as the long form, plus a title insurer or title insurance agent handling a transaction involving real property, and a person who demonstrates the certificate is necessary for a determination related to the death or protection of a personal or property right related to the death.
- Fetal death certificate: parent, sibling, grandparent, a parent's legal representative, a funeral home listed on the record (within 12 months of date of death), and a government agency or the courts (only for official duties).
An agent named in a power of attorney is also an authorized representative, as DOH defines the term, without using this form.
When to file 422-186
Complete this form when a qualified applicant wants someone else to request a certificate, and plan the timing around the 60-day limit. The authorized representative must submit the form, with a completed application for the certificate identified on it, within 60 days of the date it was notarized.
The form is for one-time use only. It cannot be used for several requests, and once 60 days have passed after notarization it must be replaced by a new form. If the two parties live in different states, each may sign before a notary in their own state; the notarizations can happen on different days, so count the 60 days from the notarization with care and submit well within the limit. DOH accepts only one complete form, not two separately notarized forms.
Documents you need
- The application for the certificate (for example the order form for a birth, death, or fetal death certificate), with the required information, submitted together with this notarized form.
- Documents proving the identity of the person requesting the certificate, required for all certificate applications.
- Documents proving the qualifying relationship: the notarized Authorized Representative Form serves as the eligibility documentation, so no separate proof is listed for it.
How to fill out 422-186
Confirm the applicant is qualified
Check the DOH list of qualified applicants for the type of record: birth, long form death, short form death or fetal death. The qualified applicant must be the one who fills out the form.
Enter the qualified applicant's name
In the declaration that begins "I," enter the qualified applicant's name, then enter the same name in Qualified Applicant's Full Name.
Add phone number and email
Complete Qualified Applicant's Phone Number and Qualified Applicant's Email Address.
State the relationship to the record
In Qualified Applicant's Relationship to Record, enter how the applicant is qualified, such as one of the relationships on the DOH list.
Identify the record and its type
Enter the name on the certificate in Full Name on Record Being Permitted, and the certificate in Type of Record (birth, death, or fetal death).
Name the authorized representative
Enter the full name of the person who will request the certificate in Authorized Representative Full Name.
Have the applicant sign before a notary
The qualified applicant signs under Qualified Applicant Signature only in the presence of a notary, who completes the date (MM/DD/YY), state, county, signature, title, printed name, commission expiration and seal.
Have the representative sign before a notary
The authorized representative signs under Authorized Representative Signature in the presence of a notary. A different notary, even in another state, may complete this block.
Review, download and print the PDF
Check that every field is complete and nothing is altered. Download or print the completed PDF from FillingPDF, take it to the notary for the signatures, and keep the 60-day limit in mind when you submit it.
How to submit 422-186
The authorized representative submits the notarized form with the certificate application, and DOH accepts that application online, by phone, by mail or in person.
- Online, phone, mail or in person: within 60 days of notarization, the authorized representative orders the certificate identified on the form by any of these channels.
- What every application needs: an application form with the required information, documents proving identity, documents proving the qualifying relationship (this form serves as the eligibility documentation) and the applicable fee(s). DOH does not state the fee on the form; check the DOH vital records website for current amounts.
- One complete form only: if two notaries were used, send a single complete form rather than two separate notarized pages.
DOH lists order forms for each record type on its vital records forms page, and more information is at https://www.doh.wa.gov/LicensesPermitsandCertificates/BirthDeathMarriageandDivorce. To request the form in another format, call 1-800-525-0127 (Washington Relay: 711) or email [email protected]. FillingPDF lets you fill out and download the PDF; submission follows the DOH channels above.
Common mistakes to avoid
- Signing without a notary present: both the qualified applicant and the authorized representative must sign in the presence of a notary.
- Leaving fields blank: the qualified applicant must fill out all the fields on the form.
- Completing the form in pencil or altering entries; the form says to complete in ink and do not alter.
- Submitting the form more than 60 days after it was notarized, or trying to use it a second time; it is one-time use only.
- A notary block missing the signature, printed name, stamp or date; the notary(ies) must sign, print their name, stamp and date.
- Sending two separately notarized forms when two notaries were used; DOH accepts only one complete form.
- Filling in the form for a person who is not a qualified applicant for that record type, such as a relationship not on the DOH list.
- Sending this form alone: it must accompany a completed application for the certificate identified on it, plus identity documents and fees.
Frequently asked questions
What is the Authorized Representative Form 422-186?
It is a Washington State Department of Health legal document that lets a qualified applicant permit another person to request a birth, death, or fetal death certificate for them. Once notarized, it serves as the eligibility documentation when the authorized representative applies for the certificate.
Does the authorized representative form have to be notarized?
Yes. The qualified applicant and the authorized representative must each sign in the presence of a notary, and the notary must sign, print their name, stamp and date the form. The form is a legal document and is completed in ink without alterations.
How long is the authorized representative form valid?
It must be used within 60 days of being notarized, and it is for one-time use only. After 60 days, or after it has been used for one request, a new notarized form is needed for another request.
Can two different notaries notarize the form?
Yes. If the qualified applicant and the representative live in different states, each may sign before a notary in their own state. DOH will accept only one complete form, not two separate notarized forms.
Who can be a qualified applicant on this form?
It depends on the record. For birth certificates, qualified applicants include the person named, spouse or domestic partner, children, parents, siblings, grandparents, grandchildren, guardians and legal representatives. Death and fetal death lists differ; see the DOH instructions on this page.
Where do I send the authorized representative form?
The authorized representative submits it with a completed certificate application within 60 days of notarization, by ordering online, by phone, by mail or in person. The application also needs identity documents and the applicable fee(s).
Can I fill out the authorized representative form online?
You can fill out the PDF online on FillingPDF and download or print it. FillingPDF does not notarize or submit it: both parties must still sign before a notary, and the representative applies to DOH through its own channels.
Do I need this form if I have a power of attorney?
Not necessarily. DOH defines an authorized representative as a person identified in a notarized form signed by a qualified applicant or an agent identified in a power of attorney, so a power of attorney is a separate way to qualify.
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