"Application for a Certified Birth Certificate Per Nrs 440.700 (4a)" - Nevada

Application for a Certified Birth Certificate Per Nrs 440.700 (4a) is a legal document that was released by the Nevada Department of Health and Human Services - a government authority operating within Nevada.

Form Details:

  • Released on December 13, 2016;
  • The latest edition currently provided by the Nevada Department of Health and Human Services;
  • Ready to use and print;
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State of Nevada
Division of Public and Behavioral Health
Bureau of Preparedness, Assurance, Inspections and Statistics
Office of Vital Records and Statistics
4150 Technology Way, Suite 104
Carson City, Nevada 89706
Telephone (775) 684-4242
http://dpbh.nv.gov
APPLICATION FOR A CERTIFIED BIRTH CERTIFICATE PER NRS 440.700 (4a)
THE APPLICANT MUST PROVIDE PHOTO IDENTIFICATION OR SUFFICIENT VERIFICATION OF
IDENTITY IN ORDER TO RECEIVE A CERTIFICATE.
Name of the Person on the Certificate:
First
Middle
Last
Date of Birth
County of Birth
State of Birth
Parent’s First and Last Name
Parent’s First and Last Name
Last Name(s) Prior to First Marriage
NRS 440.650 and NAC 440.070 requires the applicant to establish a direct relationship by blood or marriage, a
legal relationship or a need to facilitate a legal process to receive a certified copy of a record. Below, indicate
your relationship or your legal need for this record. Please provide proof such as a birth certificate or court order,
unless the applicant is the person of record or a parent listed on the certificate. The request will be rejected if
sufficient proof is not provided. Visit our website listed above for more information regarding proof required.
Relationship and Reason for Request
I hereby certify and declare under penalty of perjury under the laws of the State of Nevada that as the
person requesting this certificate that I am homeless and need a certified copy. In compliance with NRS
.
440.700 (4a), please provide a certified certificate at no charge
Applicant’s Signature
(If signing in the presence of our office, this document is exempt from the Notary requirement)
Mailing Address
FOR OFFICE USE ONLY
NOTARY PUBLIC
State of ___________________________________________
County of _________________________________________
Receipt number: _________________________
Signed and sworn to (or affirmed) ____________________
(Date)
By _______________________________________________
Date: ___________________________________
(Type or print Affiant’s name)
__________________________________________________
(Notary Public Signature)
(Seal)
(Rev.12/13/2016)
State of Nevada
Division of Public and Behavioral Health
Bureau of Preparedness, Assurance, Inspections and Statistics
Office of Vital Records and Statistics
4150 Technology Way, Suite 104
Carson City, Nevada 89706
Telephone (775) 684-4242
http://dpbh.nv.gov
APPLICATION FOR A CERTIFIED BIRTH CERTIFICATE PER NRS 440.700 (4a)
THE APPLICANT MUST PROVIDE PHOTO IDENTIFICATION OR SUFFICIENT VERIFICATION OF
IDENTITY IN ORDER TO RECEIVE A CERTIFICATE.
Name of the Person on the Certificate:
First
Middle
Last
Date of Birth
County of Birth
State of Birth
Parent’s First and Last Name
Parent’s First and Last Name
Last Name(s) Prior to First Marriage
NRS 440.650 and NAC 440.070 requires the applicant to establish a direct relationship by blood or marriage, a
legal relationship or a need to facilitate a legal process to receive a certified copy of a record. Below, indicate
your relationship or your legal need for this record. Please provide proof such as a birth certificate or court order,
unless the applicant is the person of record or a parent listed on the certificate. The request will be rejected if
sufficient proof is not provided. Visit our website listed above for more information regarding proof required.
Relationship and Reason for Request
I hereby certify and declare under penalty of perjury under the laws of the State of Nevada that as the
person requesting this certificate that I am homeless and need a certified copy. In compliance with NRS
.
440.700 (4a), please provide a certified certificate at no charge
Applicant’s Signature
(If signing in the presence of our office, this document is exempt from the Notary requirement)
Mailing Address
FOR OFFICE USE ONLY
NOTARY PUBLIC
State of ___________________________________________
County of _________________________________________
Receipt number: _________________________
Signed and sworn to (or affirmed) ____________________
(Date)
By _______________________________________________
Date: ___________________________________
(Type or print Affiant’s name)
__________________________________________________
(Notary Public Signature)
(Seal)
(Rev.12/13/2016)