Form VS 111 Application for Certified Copy of Birth Record - Mendocino County, California

Form vs111 or the "Application For Certified Copy Of Birth Record - Mendocino County" is a form issued by the California Department of Public Health.

The form was last revised in July 1, 2003 and is available for digital filing. Download an up-to-date Form vs111 in PDF-format down below or look it up on the California Department of Public Health Forms website.

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Mendocino County
Department of Public Health
APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD
NOTICE:
Orders received by mail must be accompanied by the attached sworn statement (see the instructions on
the back of this form).
The California Health and Safety Code, Section 103526, permits only authorized persons as defined below to receive certified
copies of birth records. Those who are not authorized by law to receive a certified copy will receive a certified copy marked
“INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY.” Please indicate whether you would like a
Certified Copy or a certified Informational Copy.
______________________________________________________________________________________________________
I would like a Certified Copy of the record identified on the
I would like a certified Informational Copy of
application form
the record identified on the application form
. (In order to receive a Certified Copy, you
.
must indicate your relationship to the person named on the
(You are not required to select from the list below
application form by selecting from the list below.)
in order to receive an Informational Copy.)
____________________________________________________________________________________________________
I am:
The registrant or a parent or legal guardian of the registrant.
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.
A member of a law enforcement agency or a representative of another governmental agency, as provided by law, who is conducting
official business.
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.
STOP!
DO NOT complete the rest of this form before reading the detailed instructions on the back.
(PLEASE PRINT OR TYPE)
APPLICANT INFORMATION
Printed Name and Signature of Person Requesting Record
Today’s Date
Telephone Number – Area Code First
(
)
Address – Number, Street
City
State
ZIP Code
Name of Person Receiving Copies, if Different From Above
No. of Copies
Amount Enclosed
E-mail Address
Mailing Address for Copies, If Different From Above
City
State
ZIP Code
(PLEASE PRINT OR TYPE)
BIRTH CERTIFICATE INFORMATION
Name on Certificate – First Name
Name on Certificate – Middle Name
Name on Certificate – Last Name
City or Town of Birth
Place of Birth – County
Sex
Date of Birth – Month, Day, Year (If unknown, enter approximate date of birth)
Female
Male
Name on Certificate – Father ‘s First Name
Name on Certificate – Father’s Middle Name
Name on Certificate – Father’s Last Name
Name on Certificate – Mother’s First Name
Name on Certificate – Mother’s Middle Name
Name on Certificate – Mother’s Last Name
BIRTH
VS 111 (7/03)
Mendocino County
Department of Public Health
APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD
NOTICE:
Orders received by mail must be accompanied by the attached sworn statement (see the instructions on
the back of this form).
The California Health and Safety Code, Section 103526, permits only authorized persons as defined below to receive certified
copies of birth records. Those who are not authorized by law to receive a certified copy will receive a certified copy marked
“INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY.” Please indicate whether you would like a
Certified Copy or a certified Informational Copy.
______________________________________________________________________________________________________
I would like a Certified Copy of the record identified on the
I would like a certified Informational Copy of
application form
the record identified on the application form
. (In order to receive a Certified Copy, you
.
must indicate your relationship to the person named on the
(You are not required to select from the list below
application form by selecting from the list below.)
in order to receive an Informational Copy.)
____________________________________________________________________________________________________
I am:
The registrant or a parent or legal guardian of the registrant.
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.
A member of a law enforcement agency or a representative of another governmental agency, as provided by law, who is conducting
official business.
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.
STOP!
DO NOT complete the rest of this form before reading the detailed instructions on the back.
(PLEASE PRINT OR TYPE)
APPLICANT INFORMATION
Printed Name and Signature of Person Requesting Record
Today’s Date
Telephone Number – Area Code First
(
)
Address – Number, Street
City
State
ZIP Code
Name of Person Receiving Copies, if Different From Above
No. of Copies
Amount Enclosed
E-mail Address
Mailing Address for Copies, If Different From Above
City
State
ZIP Code
(PLEASE PRINT OR TYPE)
BIRTH CERTIFICATE INFORMATION
Name on Certificate – First Name
Name on Certificate – Middle Name
Name on Certificate – Last Name
City or Town of Birth
Place of Birth – County
Sex
Date of Birth – Month, Day, Year (If unknown, enter approximate date of birth)
Female
Male
Name on Certificate – Father ‘s First Name
Name on Certificate – Father’s Middle Name
Name on Certificate – Father’s Last Name
Name on Certificate – Mother’s First Name
Name on Certificate – Mother’s Middle Name
Name on Certificate – Mother’s Last Name
BIRTH
VS 111 (7/03)
:
Birth records are maintained in this office for the current year and one year past. All other
INFORMATION
years, including years mentioned above are kept at the Mendocino County Assessor Clerk Recorders
Office.
Their phone number is (707) 463-4376
INSTRUCTIONS
If you are requesting a certified Informational Copy, complete only the Applicant Information and Birth
1.
Certificate Information portions of this form. If you are requesting a regular Certified Copy, complete the
entire form.
If you submit your order in person, you must sign a sworn statement in the presence of Office of Vital
2.
Records staff. If you submit your request by mail, you must complete the attached statement and sign it in
the presence of a Notary Public. PLEASE NOTE: Only one notarized sworn statement is required for
multiple certificates requested at the same time; however, the sworn statement must include the
name of each individual whose birth certificate you wish to obtain and your relationship to that
individual.
Use a separate application form for each different record of birth for which you are requesting a certified
4.
copy (if submitting your request by mail, remember to identify each certificate requested on the sworn
statement).
Complete the Applicant Information section and provide your signature where indicated. Give all the
5.
information you have available to identify the record of the registrant in the spaces under Birth Certificate
Information. If the information you furnish is incomplete or inaccurate, it may be impossible to locate the
record. If the registrant has been adopted, please make the request in the adopted name.
6. Submit $20 for each certified copy requested. If no record of the birth is found, the $20 fee will be retained
for searching as required by statute and a Certificate of No Public Record will be issued. If you are mailing
your request, indicate the number of certified copies you wish and include sufficient money with this
application, in the form of a personal check, postal or bank money order (International Money Order only for
out-of-country requests) made payable to the Mendocino County Public Health. Mail this application with
the fee(s) to the Mendocino County Public Health, Attn: RoseMary, 1120 S. Dora Street, Ukiah, CA.
95482 (707) 472-2772
Mendocino County Public Health
Attn: RoseMary
1120 S. Dora Street
Ukiah, CA. 95482
(707)472--2772
BIRTH
VS 111 (7/03)
State of California – Health and Human Services Agency
Department of Health Services
SWORN STATEMENT
I, ___________________________________, swear under penalty of perjury under the laws of the State of California,
(Printed Name)
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 or death record of the following individual(s):
Name of Person Listed on Certificate
Relationship to Person Listed on Certificate
Sworn this ______ day of ______________, 20___, at ________________________________, _____________.
(Day)
(Month)
(City)
(State)
______________________________________________________
(Signature)
Note: If submitting your order by mail, you must have your sworn statement notarized using the Certificate of
Acknowledgment below.
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
CERTIFICATE OF ACKNOWLEDGMENT
State of _______________________)
) ss
County of ______________________)
On ____________________, before me personally appeared _______________________________________,
personally known to me, or
proved to me on the basis of satisfactory evidence, to be the person whose
name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her authorized capacity,
and that by his/her signature on the instrument the person, or the entity upon behalf of which the person acted, executed the
instrument.
WITNESS my hand and official seal.
(NOTARY SEAL)
__________________________________________
NOTARY SIGNATURE

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