Application for Certified Copy of Birth Record - County of Santa Barbara, California

The California Department of Public Health has released this version of the "Application for Certified Copy of Birth Record" on July 22, 2016.

This form may be used by all California residents: download the printable PDF by clicking the link below and use it according to the applicable legal guidelines.

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SANTA BARBARA COUNTY CLERK RECORDER
APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD
Applications for certified copies of birth records can be submitted
THREE (3) ways:
IN PERSON: $28.00 per copy at either of our two (2) offices.
Please fill out the application and sworn statement and be prepared to show government issued photo ID.
All records from 1965 to the present can immediately be obtained over the counter.
All previous records may have a wait time of between 15 minutes to one day.
Physical Addresses:
Santa Barbara County Recorder
Santa Maria Government Center
Hall of Records, County Courthouse
511 East Lakeside Parkway #115
1100 Anacapa Street
Santa Maria, CA. 93455
Santa Barbara, CA 93101
(805) 346-8370
(805) 568-2250
BY MAIL:
$30.00 First Class Mail or $51.50 U.S. Post Office express delivery mail.
Note: Add $28.00 per additional copy.
Sworn statement and acknowledgment must be properly filled out.
Requests are processed within 7-10 business days if all requirements are met.
Mailing Address:
Santa Barbara County Recorder
P. O. Box 159
Santa Barbara, CA 93102-0159
FAXED IN: $58.50 and delivered U.S. Post Office express delivery mail.
Note: Add $28.00 per additional copy.
Sworn statement and acknowledgment must be properly filled out.
Requests are processed between 1-3 business days if all requirements are met.
FAX NUMBER:
(805) 568-2266
www.sbcrecorder.com
For more information, please visit our website
Rev. 7/22/2016
SANTA BARBARA COUNTY CLERK RECORDER
APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD
Applications for certified copies of birth records can be submitted
THREE (3) ways:
IN PERSON: $28.00 per copy at either of our two (2) offices.
Please fill out the application and sworn statement and be prepared to show government issued photo ID.
All records from 1965 to the present can immediately be obtained over the counter.
All previous records may have a wait time of between 15 minutes to one day.
Physical Addresses:
Santa Barbara County Recorder
Santa Maria Government Center
Hall of Records, County Courthouse
511 East Lakeside Parkway #115
1100 Anacapa Street
Santa Maria, CA. 93455
Santa Barbara, CA 93101
(805) 346-8370
(805) 568-2250
BY MAIL:
$30.00 First Class Mail or $51.50 U.S. Post Office express delivery mail.
Note: Add $28.00 per additional copy.
Sworn statement and acknowledgment must be properly filled out.
Requests are processed within 7-10 business days if all requirements are met.
Mailing Address:
Santa Barbara County Recorder
P. O. Box 159
Santa Barbara, CA 93102-0159
FAXED IN: $58.50 and delivered U.S. Post Office express delivery mail.
Note: Add $28.00 per additional copy.
Sworn statement and acknowledgment must be properly filled out.
Requests are processed between 1-3 business days if all requirements are met.
FAX NUMBER:
(805) 568-2266
www.sbcrecorder.com
For more information, please visit our website
Rev. 7/22/2016
SANTA BARBARA COUNTY CLERK AND RECORDER
APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD
The California Health and Safety Code, section 103526, permits only authorized persons as defined below to receive authorized
certified copies of birth records. Those who are not authorized by law to receive an authorized certified copy will receive a
certified copy marked “INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY.”
PLEASE INDICATE WHETHER YOU WOULD LIKE A CERTIFIED AUTHORIZED COPY OR A CERTIFIED INFORMATIONAL COPY
I request a Certified Authorized Copy. This copy will establish
I request a Certified Informational Copy. This
the identity of the registrant. (To receive an Authorized Copy you
document will be printed with a legend on the face of
must indicate your relationship to the registrant by selecting from
the document that states, “INFORMATIONAL, NOT
the list below AND complete the attached Sworn Statement
A VALID DOCUMENT TO ESTABLISH IDENTITY.”
declaring you are eligible to receive the Authorized Copy. Your
A sworn statement does not need to be provided.
signature on the Sworn Statement must be acknowledged by a
Notary Public if the application is submitted by mail or fax.)
******NOTE: ALL FAXED IN REQUESTS WILL BE RETURNED BY: EXPRESS MAIL ONLY*******
MAILED IN
First class (standard ground)
Express Mail (U. S. Postal Service Express delivery)
REQUESTS:
To receive an Authorized Certified Copy I am:
The registrant (person listed on the certificate) or a parent or legal guardian of the registrant. (Legal guardian must provide
documentation.)
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. (Please provide a copy of the court order.)
A member of a law enforcement agency or a representative of another governmental agency, as provided by law, who is conducting
official business. (Companies representing a government agency must provide authorization from the government agency.)
A child, grandparent, grandchild, sibling, spouse, or domestic partner of the registrant.
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. (Please include a copy of the power of attorney or supporting documentation
identifying you as executor.)
APPLICANT INFORMATION
(PLEASE PRINT OR TYPE)
Today’s Date
Printed Name of Applicant
Signature of Applicant
Telephone Number – Area Code First
Email Address
(
)
Address – Number, Street
City
State
ZIP Code
(IF FAXED OR MAILED) Recipient, if different from applicant
No. of Copies
Amount Enclosed
Purpose of Request
Mailing Address for Copies, If Different From Above
City
State
ZIP Code
BIRTH CERTIFICATE INFORMATION
WAS THERE A LEGAL NAME CHANGE/ADOPTION? Yes ___ No___
(PLEASE PRINT OR TYPE)
Name on Certificate – First Name
Name on Certificate – Middle Name
Name on Certificate – Last Name
Place of Birth – County
City or Town of Birth
Sex
Date of Birth – Month, Day, Year (If unknown, enter approximate date of birth)
Female
Male
Father/Parent Name on Certificate – First Name
Middle Name
Last Name at Birth/Maiden Name
Mother/Parent Name on Certificate – First Name
Middle Name
Last Name at Birth/Maiden Name
PLEASE COMPLETE THE NEXT PAGE
APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD (REV 7/22/16)
TRANSACTION # ___________________________________________
SWORN STATEMENT
(*Required for certified authorized copy of record. This Sworn Statement is not required when requesting
an Informational certified copy which is not valid to establish identity)
*Any member of a law enforcement agency or a representative of a state or local government agency, as provided by law, who
orders a copy of a record to which subdivision (a) applies in conducting official business must complete the Sworn Statement,
however, they may not be required to have their signature on the Sworn Statement acknowledged by a Notary Public.
I, _
________________________________, declare under penalty of perjury under the laws of the State of California,
(Printed Name of Applicant)
that I am an authorized person, as defined in California Health and Safety Code Section 103526 (c), and am eligible to receive a
certified copy of the birth record of the following individual(s):
Your Relationship to the Person Listed on the Birth Certificate
Name of Person Listed on the Birth Certificate
(I.E. Self/Parent)
(The remaining information must be completed in the presence of a Notary Public or County Clerk and Recorder staff.)
Subscribed to this _______ day of ______________, 20___, at _________________________, ________________
(Day)
(Month)
(City)
(State)
YOU MUST SIGN IN FRONT OF A NOTARY PUBLIC OR COUNTY CLERK STAFF
______________________________________________________
(Signature of person requesting certified copy)
Note: If submitting your order by mail or fax, you must have your signature on the Sworn Statement
acknowledged by a Notary Public using the Certificate of Acknowledgment below.
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
CERTIFICATE OF ACKNOWLEDGMENT
A notary public or other officer completing this certificate verifies only the
identity of the individual who signed the document to which this certificate is
attached, and not the truthfulness, accuracy, or validity of that document.
State of ____________________)
County of ___________________)
On ________________, before me, ___________________________________________________,
Notary Public , personally
(insert name of Officer)
(Title of Officer)
appeared __________________________________________________________________________, who proved to me on the
basis of satisfactory evidence to be the person(s) whose name 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.
(NOTARY SEAL)
____________________________________________________
NOTARY SIGNATURE
YOU MUST COMPLETE THE CREDIT CARD AUTHORIZATION FORM WHEN MAILING YOUR REQUEST
AND PAYING FEES WITH A CREDIT CARD OR WHEN FAXING IN YOUR EXPEDITED REQUEST
APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD (REV 7/22/16)
J
E. H
Hall of Records
OSEPH
OLLAND
1100 Anacapa St.
County Clerk, Recorder and Assessor
Santa Barbara, CA 93101
Registrar of Voters
Mailing Address:
MELINDA GREENE
PO Box 159
Santa Barbara, CA 93102
Chief Deputy Clerk-Recorder
C
C
, R
A
OUNTY
LERK
ECORDER AND
SSESSOR
C
-R
D
LERK
ECORDER
IVISION
CLERK-RECORDER CREDIT CARD AUTHORIZATION FORM
VISA/MASTERCARD/DISCOVER ONLY
NO AMERICAN EXPRESS
I hereby authorize the Office of the County Clerk-Recorder to charge the following credit card for
payment of requested service:
Applicant Name: ___________________________________________________
Phone #: (______) __________________________________________________
Cardholder
: __________________________________
(name as appears on credit card)
Credit Card Number: ___________________________Exp Date: ____ /______
(American Express Not Accepted)
Address:___________________________________________________________
City: _______________________________ State: _______ Zip: _____________
Cardholder Phone Number: (_____) ___________________________________
Cardholder Signature: ___________________________Date: ____/____/_____
Note: This credit card authorization form will be kept on file for 60 days from date of service. Any disputed charges made in
conjunction with this request, shall be made within 45 days from date of service.
OFFICE USE ONLY
Transaction #: _____________________
Website Address:
WWW.SBCRECORDER.COM
Santa Barbara Office (805) 568-2250 Fax (805) 568-2266

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