Birth Certificate Application Form - City of Pasadena, California

This "Birth Certificate Application Form" is a California-specific form released by the California Department of Public Health on June 1, 2017.

Download the form by clicking the link below, fill it out by hand, and mail it as per the guidelines provided by the department or the applicable legal instructions.

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(PLEASE PRINT CLEARLY)
BIRTH CERTIFICATE APPLICATION FORM
Birth certificates may be purchased as long as the birth occurred in the incorporated areas of the City of Pasadena. If we cannot
identify the record based on the information provided, fees will be retained and a “Letter of No Record” will be issued. Fees are
non-refundable, even if the record is not found. You will be asked to present a valid photo ID for all in-person requests.
⃝ Certified Copy
⃝ Informational Copy
You may establish identity with this type of copy
You may NOT establish identity with this type copy
1. BIRTH CERTIFICATE INFORMATION (REGISTRANT)
No. of copies______
Please wait 3 weeks from the date of the event before submitting your request.
First Name
Middle Name
Last Name (Name Given at Birth)
Name of Hospital in Pasadena
Was there an adoption,
Sex
Date of Birth
amendment or name change?
⃝Female
⃝Yes ⃝No
⃝Male
Mother/Father/Parent First Name
Middle Name
Last Name (Before Marriage/Domestic Partnership)
Mother/Father/Parent First Name
Middle Name
Last Name (Before Marriage/Domestic Partnership)
2. APPLICANT INFORMATION (REQUESTOR)
First Name
Middle Name
Last Name
Mailing Address (Number, Street)
Apt #/Unit
Telephone Number
(
)
City
State
ZIP Code
Per California State Law, Health and Safety Code, Section 103526 (c), 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
informational copy marked “Informational, Not a Valid Document to Establish Identity.” Request for an informational copy do
not require a sworn statement and do not require an item to be selected from the list below.
To receive a 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 include a copy of
the court order.)
⃝ A member of a law enforcement agency or a representative of another government 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, brother or sister, 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.
⃝ Appointed rights in a power of attorney, or an executor of the registrant’s estate. (Please include a copy of the power of
attorney, or supporting documentation identifying you as executor.)
Page 1 of 2
Revised 6/2017
(PLEASE PRINT CLEARLY)
BIRTH CERTIFICATE APPLICATION FORM
Birth certificates may be purchased as long as the birth occurred in the incorporated areas of the City of Pasadena. If we cannot
identify the record based on the information provided, fees will be retained and a “Letter of No Record” will be issued. Fees are
non-refundable, even if the record is not found. You will be asked to present a valid photo ID for all in-person requests.
⃝ Certified Copy
⃝ Informational Copy
You may establish identity with this type of copy
You may NOT establish identity with this type copy
1. BIRTH CERTIFICATE INFORMATION (REGISTRANT)
No. of copies______
Please wait 3 weeks from the date of the event before submitting your request.
First Name
Middle Name
Last Name (Name Given at Birth)
Name of Hospital in Pasadena
Was there an adoption,
Sex
Date of Birth
amendment or name change?
⃝Female
⃝Yes ⃝No
⃝Male
Mother/Father/Parent First Name
Middle Name
Last Name (Before Marriage/Domestic Partnership)
Mother/Father/Parent First Name
Middle Name
Last Name (Before Marriage/Domestic Partnership)
2. APPLICANT INFORMATION (REQUESTOR)
First Name
Middle Name
Last Name
Mailing Address (Number, Street)
Apt #/Unit
Telephone Number
(
)
City
State
ZIP Code
Per California State Law, Health and Safety Code, Section 103526 (c), 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
informational copy marked “Informational, Not a Valid Document to Establish Identity.” Request for an informational copy do
not require a sworn statement and do not require an item to be selected from the list below.
To receive a 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 include a copy of
the court order.)
⃝ A member of a law enforcement agency or a representative of another government 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, brother or sister, 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.
⃝ Appointed rights in a power of attorney, or an executor of the registrant’s estate. (Please include a copy of the power of
attorney, or supporting documentation identifying you as executor.)
Page 1 of 2
Revised 6/2017
3. SWORN STATEMENT* (Must be signed in the presence of the Pasadena Vital Records Staff or a Notary Public.)
I, _________________________________________, declare under penalty of perjury under the laws of the State of California,
(Applicant’s 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 certificate identified on this application form.
Subscribed to this__________ day of ____________________, 20______, at ______________________________, ________.
(Day)
(Month)
(City)
(State)
___________________________________
(Applicant’s Signature)
*If you are requesting a certified copy by mail, you must have the above statement and the certificate of acknowledgement
notarized. Please note: The notary is not certifying the relationship, only that you are the person requesting the copy.
Requests for an informational copy do not require your signature to be notarized.
SUBMITTING APPLICATION
By Mail:
Payment may be made by check or money order made payable to the City of Pasadena Public Health Department.
Do not mail cash.
Please provide a self-addressed stamped envelope.
The document(s) will be mailed to you within seven (7) business days.
In Person:
You will be asked to present valid photo identification.
Payment may be made with a credit card (American Express, Discover, MasterCard, Visa, Debit) cash or by
check/money order made payable to the City of Pasadena Public Health Department.
Please send or bring your completed application with the appropriate fee(s) to:
City of Pasadena Public Health Department
Vital Records Office
1845 North Fair Oaks Avenue, Room 1610
Pasadena, CA 91103
http://ww5.cityofpasadena.net/public-health/birth-and-death-records/
(626) 744-6010
OFFICE USE ONLY:
ID/DL#:__________________Exp:__________ LRN#:__________BN#:___________________________City Official: ______
⃝ Mail out
⃝ Hold for Pick-Up
⃝ Express/Same day service (additional fee required)
Page 2 of 2
Revised 6/2017

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