"Application for Certified Copy of Birth Certificate" - California

Application for Certified Copy of Birth Certificate is a legal document that was released by the California Department of Public Health - a government authority operating within California.

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Download "Application for Certified Copy of Birth Certificate" - California

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APPLICATION FOR CERTIFIED COPY OF BIRTH CERTIFICATE
Name of Child
(Registrant)
First
Middle
Last
Father’s
Name:
Mother’s
Name:
Date of Birth:
Month/Date/Year
Place of Birth
City or Town
Name of
Applicant:
First
Middle
Last
Mailing
Address:
Number & Street
City & State
Zip Code
Phone
Home:
Cell:
Number:
Please Check The Appropriate Box:
I am the registrant or a parent or legal guardian
I am a child, grandparent, grandchild, sibling, spouse, or domestic partner
I am a party entitled to receive the certificate as a result of court order, or an attorney or a licensed adoption agency
seeking the birth certificate in order to comply with the requirements of section 3140 or 7603 of the family code.
I am an attorney representing the registrant of the registrants estate or any person or agency empowered by
statute or appointed by a court to act on behalf of the registrant or the registrants estate
I am a member of a law enforcement agency or a representative of another government agency as provided
bylaw who is conducting official business
-OR-
I do not qualify as an authorized requestor and am requesting a Certified Informational Copy only.
I understand this copy will be stamped “Informational, Not a valid document to establish identity”.
I declare under penalty of perjury under the laws of the State of California that the above information is true and correct.
City/State where signed
Signature of Applicant
Date_
If applying by mail, and the applicant is an authorized requestor, the applicant’s signature must be notarized and the
acknowledgement must be attached to this application. No acknowledgement is necessary if requesting a certified
informational copy only.
For Official Use Only
Initial of Clerk Issuing Copy
Date Copy Issued
ID #
Receipt #
Type Issued:
_Certified
Informational
CDL
Other
Certificate #
Order Method:
In Person
Mail
APPLICATION FOR CERTIFIED COPY OF BIRTH CERTIFICATE
Name of Child
(Registrant)
First
Middle
Last
Father’s
Name:
Mother’s
Name:
Date of Birth:
Month/Date/Year
Place of Birth
City or Town
Name of
Applicant:
First
Middle
Last
Mailing
Address:
Number & Street
City & State
Zip Code
Phone
Home:
Cell:
Number:
Please Check The Appropriate Box:
I am the registrant or a parent or legal guardian
I am a child, grandparent, grandchild, sibling, spouse, or domestic partner
I am a party entitled to receive the certificate as a result of court order, or an attorney or a licensed adoption agency
seeking the birth certificate in order to comply with the requirements of section 3140 or 7603 of the family code.
I am an attorney representing the registrant of the registrants estate or any person or agency empowered by
statute or appointed by a court to act on behalf of the registrant or the registrants estate
I am a member of a law enforcement agency or a representative of another government agency as provided
bylaw who is conducting official business
-OR-
I do not qualify as an authorized requestor and am requesting a Certified Informational Copy only.
I understand this copy will be stamped “Informational, Not a valid document to establish identity”.
I declare under penalty of perjury under the laws of the State of California that the above information is true and correct.
City/State where signed
Signature of Applicant
Date_
If applying by mail, and the applicant is an authorized requestor, the applicant’s signature must be notarized and the
acknowledgement must be attached to this application. No acknowledgement is necessary if requesting a certified
informational copy only.
For Official Use Only
Initial of Clerk Issuing Copy
Date Copy Issued
ID #
Receipt #
Type Issued:
_Certified
Informational
CDL
Other
Certificate #
Order Method:
In Person
Mail
State of California – Health and Human Services Agency
California Department of Public Health
SWORN STATEMENT
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, death, or marriage certificate of the following individual(s):
Applicant’s Relationship to Person Listed on Certificate
Name of Person Listed on Certificate
(Must Be a Relationship Listed on Page 1 of Application)
(The remaining information must be completed in the presence of a Notary Public or CDPH Vital Records staff.)
Subscribed to this ______ day of ______________, 20___, at ________________________________, _____________.
(Day)
(Month)
(City)
(State)
______________________________________________________
(Applicant’s Signature)
Note: If submitting your order by mail, you must have your Sworn Statement notarized using the Certificate of Acknowledgment
below. The Certificate of Acknowledgment must be completed by a Notary Public. (Law enforcement and local and state
governmental agencies are exempt from the notary requirement.)
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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, _________________________________, personally appeared _______________________________________,
(insert name and title of the officer)
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.
(SEAL)
_________________________________________________________
SIGNATURE OF NOTARY PUBLIC
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