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2Clear Form
Print
W
A
F
U
RITTEN
PPLICATION
OR
NRESTRICTED
C
C
B
R
ERTIFIED
OPY OF A
IRTH
ECORD
$32.00 general public or $19.00 government agencies only
Please review the instructions on the back before completing
Number of copies requested
1
Name:
First
Middle
Last
Date of Birth:
City of Birth:
Month
Day
Year
Father/Parent Name:
First
Middle
Last
Mother/Parent Maiden Name:
First
Middle
Last
Adoption (Circle one) Yes
No
Applicant Information
2
Name:
First
Middle
Last
Address
Number and Street
City
State
Zip Code
Mailing Address:
(If different from above) Number and Street
City
State
Zip Code
Telephone Number:
(
)
(with area code)
To obtain an Unrestricted Certified Copy you must be authorized under section 103526 of the Health and
3
Safety Code. Please review the reverse side of this application to determine which section applies and
check the appropriate box below.
103526(c)(2)(A)
103526(c)(2)(B)
103526(c)(2)(C)
103526(c)(2)(E)
103526(c)(2)(F)
103526(b)(1)(info copy)
103526(c)(2)(D)
I
swear under penalty of perjury that I am an authorized person,
4
(printed name)
as defined in California Health and Safety Code Section 103526 (c), and am eligible to receive a certified copy of the
birth record identified on this application form. Sworn this
day of
,
,
at
Signature:
(City)
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to
5
which this certificate is attached, and not the truthfulness, accuracy or validity of that document.
Certificate of Acknowledgment
State of
County of
Notary public
On
before me,
, personally appeared
,
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument
and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their
signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and
correct.
WITNESS my hand and official seal.
Signature______________________________
(seal)
Office Use Only:
Reel/Image
Paper#
Deputy
Birth written unrestricted app
1/15
Clear Form
Print
W
A
F
U
RITTEN
PPLICATION
OR
NRESTRICTED
C
C
B
R
ERTIFIED
OPY OF A
IRTH
ECORD
$32.00 general public or $19.00 government agencies only
Please review the instructions on the back before completing
Number of copies requested
1
Name:
First
Middle
Last
Date of Birth:
City of Birth:
Month
Day
Year
Father/Parent Name:
First
Middle
Last
Mother/Parent Maiden Name:
First
Middle
Last
Adoption (Circle one) Yes
No
Applicant Information
2
Name:
First
Middle
Last
Address
Number and Street
City
State
Zip Code
Mailing Address:
(If different from above) Number and Street
City
State
Zip Code
Telephone Number:
(
)
(with area code)
To obtain an Unrestricted Certified Copy you must be authorized under section 103526 of the Health and
3
Safety Code. Please review the reverse side of this application to determine which section applies and
check the appropriate box below.
103526(c)(2)(A)
103526(c)(2)(B)
103526(c)(2)(C)
103526(c)(2)(E)
103526(c)(2)(F)
103526(b)(1)(info copy)
103526(c)(2)(D)
I
swear under penalty of perjury that I am an authorized person,
4
(printed name)
as defined in California Health and Safety Code Section 103526 (c), and am eligible to receive a certified copy of the
birth record identified on this application form. Sworn this
day of
,
,
at
Signature:
(City)
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to
5
which this certificate is attached, and not the truthfulness, accuracy or validity of that document.
Certificate of Acknowledgment
State of
County of
Notary public
On
before me,
, personally appeared
,
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument
and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their
signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and
correct.
WITNESS my hand and official seal.
Signature______________________________
(seal)
Office Use Only:
Reel/Image
Paper#
Deputy
Birth written unrestricted app
1/15
I
T
C
W
A
F
NSTRUCTIONS
O
OMPLETE
RITTEN
PPLICATION
OR
U
C
C
O
B
R
NRESTRICTED
ERTIFIED
OPY
F A
IRTH
ECORD
1
Print or type number of copies requested
Print or type name of registrant
Print or type date of birth
Print or type city of birth
Print or type father’s name
Print or type mother’s maiden name
Applicant Information:
2
Print or type name of person ordering copy
Print or type address of person ordering copy
Print or type mailing address of person ordering copy, if different than address above
Print or type telephone number of person ordering copy, including area code
Using the list below, check the box next to the code section in item 3 on the front of this application that
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103526 (c)(2)(A) The registrant or a parent or legal guardian of the registrant
103526 (c)(2)(B) A party entitled to receive the record as a result of a court order, or an attorney or a licensed
adoption agency seeking the birth record in order to comply with the requirements of Section 3140 or 7603 of the
Family Code.
103526 (c)(2)(C) A member of a law enforcement agency or a representative of another governmental agency, as
provided by law, who is conducting official business.
103526 (c)(2)(D) A child, grandparent, grandchild, sibling, spouse or domestic partner of the registrant.
103526 (c)(2)(E) An attorney representing the registrant or the registrant’s estate, or any person or agency empowered
by statute or appointed by a court to act on behalf of the registrant or the registrant’s estate.
103526 (c)(2)(F) Any funeral director who orders certified copies of a death certificate on behalf of any individual
specified in paragraphs (1) to (5), inclusive, of subdivision (a) or Section 7100 of the Health and Safety Code.
103526 (b)(1) If the person requesting a certified copy of a birth, death, or nonconfidential marriage record is not an
authorized person or is an authorized person who is otherwise unable to satisfy the requirements of subdivision (a),
the certified copy provided to the applicant shall be an informational certified copy and shall display a legend that
states “ INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY ”
DO NOT COMPLETE THIS PART UNTIL YOU ARE WITH THE NOTARY PUBLIC WHO WILL PREPARE
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THE CERTIFICATE OF ACKNOWLEDGMENT IN ITEM 5.
If requesting a copy in person, notarization is not necessary. Please complete the Sworn Statement and present
it to the Customer Service Representative. Section 103526 of the California Health and Safety Code requires anyone
requesting an unrestricted certified copy of a birth record to complete and sign a sworn statement under penalty of
perjury.
.
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Certificate of Acknowledgment
Complete items 1 to 3 on the front of this application then bring to a notary public. Complete and sign the sworn
statement in item 4 in front of the notary public. Request the notary acknowledge your signature in the sworn
statement in item 4. Mail the original application with the appropriate fee ($32.00 general public or $19.00
government agencies only).
To: Contra Costa Recorder
P.O. Box 350
Martinez, CA 94553
Birth written unrestricted app
1/15
