"Application for Certified Copy of Birth Record" - County of San Bernardino, California

Application for Certified Copy of Birth Record is a legal document that was released by the California Department of Public Health - a government authority operating within California. The form may be used strictly within County of San Bernardino.

Form Details:

  • Released on January 1, 2014;
  • The latest edition currently provided by the California Department of Public Health;
  • Ready to use and print;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download "Application for Certified Copy of Birth Record" - County of San Bernardino, California

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County of San Bernardino – Department of Public Health
APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD
NOTICE: Orders received by mail must have an attached notarized sworn statement. (See instructions)
The California Health and Safety Code, Section 103526, permits only authorized persons as defined below to receive a certified
Copy of a birth records. Those who are not authorized by law to receive a certified copy will receive an informational certified copy
marked “INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY.” Please indicate whether you would like an
Authorized Certified Copy or a Certified Informational Copy. If the requestor will use the certificate to obtain a driver’s license, state
I.D.card, passport, or apply for insurance coverage, then a Certified copy must be obtained.
The search fee is the same as the fee for Certified copy. Any questions please contact our office at (909) 381-8990.
____________________________________________________________________________________________________
I would like a Certified Copy of the record identified on the
I would like a certified Informational Copy. This
application form
document will be printed with a legend on the face
. (In order to receive a Certified Copy, you
of the document that states, “INFORMATIONAL NOT
must indicate your relationship to the person named on the
A VALID DOCUMENT TO ESTABLISH IDENTITY”
application form by selecting from the list below.)
(A Sworn Statement does not need to be provided)
Note: Both documents are Certified copies of the original document on file. With the exception of the legend,
the documents contain the same exact information.
To receive a Certified 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.
IF MAILING APPLICATION, ATTACHED SWORN STATEMENT MUST BE NOTARIZED.
APPLICANT INFORMATION (PLEASE PRINT)
Today’s Date
Printed Name
(Person Requesting the Copy/ies)
Telephone Number
(
)
Address – Number, Street
City
State
ZIP Code
Name of Person Receiving Copies, if Different From Above
No. of Copies
Mailing Address for Copies, If Different From Above
City
State
ZIP Code
BIRTH CERTIFICATE INFORMATION
(PLEASE PRINT)
Name on Certificate – Child’s First Name
Child’s Middle Name
Child’s Last Name
Place of Birth – County
City or Town of Birth
Date of Birth – Month, Day, Year (If unknown, enter approximate date of birth)
Sex
Female
Male
Name on Certificate – Father ‘s First Name
Father’s Middle Name
Father’s Last Name
Name on Certificate – Mother’s First Name
Mother’s Middle Name
Mother’s Last Name (Maiden/Birth Name)
BIRTH
Rev 01/14
County of San Bernardino – Department of Public Health
APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD
NOTICE: Orders received by mail must have an attached notarized sworn statement. (See instructions)
The California Health and Safety Code, Section 103526, permits only authorized persons as defined below to receive a certified
Copy of a birth records. Those who are not authorized by law to receive a certified copy will receive an informational certified copy
marked “INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY.” Please indicate whether you would like an
Authorized Certified Copy or a Certified Informational Copy. If the requestor will use the certificate to obtain a driver’s license, state
I.D.card, passport, or apply for insurance coverage, then a Certified copy must be obtained.
The search fee is the same as the fee for Certified copy. Any questions please contact our office at (909) 381-8990.
____________________________________________________________________________________________________
I would like a Certified Copy of the record identified on the
I would like a certified Informational Copy. This
application form
document will be printed with a legend on the face
. (In order to receive a Certified Copy, you
of the document that states, “INFORMATIONAL NOT
must indicate your relationship to the person named on the
A VALID DOCUMENT TO ESTABLISH IDENTITY”
application form by selecting from the list below.)
(A Sworn Statement does not need to be provided)
Note: Both documents are Certified copies of the original document on file. With the exception of the legend,
the documents contain the same exact information.
To receive a Certified 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.
IF MAILING APPLICATION, ATTACHED SWORN STATEMENT MUST BE NOTARIZED.
APPLICANT INFORMATION (PLEASE PRINT)
Today’s Date
Printed Name
(Person Requesting the Copy/ies)
Telephone Number
(
)
Address – Number, Street
City
State
ZIP Code
Name of Person Receiving Copies, if Different From Above
No. of Copies
Mailing Address for Copies, If Different From Above
City
State
ZIP Code
BIRTH CERTIFICATE INFORMATION
(PLEASE PRINT)
Name on Certificate – Child’s First Name
Child’s Middle Name
Child’s Last Name
Place of Birth – County
City or Town of Birth
Date of Birth – Month, Day, Year (If unknown, enter approximate date of birth)
Sex
Female
Male
Name on Certificate – Father ‘s First Name
Father’s Middle Name
Father’s Last Name
Name on Certificate – Mother’s First Name
Mother’s Middle Name
Mother’s Last Name (Maiden/Birth Name)
BIRTH
Rev 01/14
County of San Bernardino – Department of Public Health
SWORN STATEMENT
(The Applicant must complete in the presence of a Notary or Vital Records Staff.)
I, ____________________________, declare under penalty of perjury under the laws of the State of California, that
(Applicant’s Printed Name)
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):
Applicant’s Relationship to Person Listed on Certifcate
Name of Person Listed on Certificate (Registrant)
(Must be a Relationship Listed on Page 1 of Application)
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
Acknowledgement below. The Certificate of Acknowledgement must be completed by a Notary Public.
(Law enforcement and local and state governmental agencies are exempt from the notary requirement.)
CERTIFICATE OF ACKNOWLEDGEMENT
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 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 the PENALTY OF PERJURY under the laws of the State of California the
foregoing paragraph is true and correct.
WITNESS my hand and official seal.
(SEAL)
__________________________________________
SIGNATURE OF NOTARY PUBLIC
(January 1, 2015)
INSTRUCTIONS
A. If you are requesting an Authorized Certified Copy:
1. Complete the application form, one for each individual whose birth certificate you are requesting,
indicating on each how you are related to the individual (mark the appropriate box from the list).
NOTE: If the child is adopted, please make the request in the adopted name.
2. Complete the Sworn Statement
NOTE: Only one sworn statement is required if you are requesting multiple certificates at the same
time; however, the sworn statement must include the name of each individual whose birth certificate
you are requesting and your relationship to that individual.
a. Sign the Sworn Statement in front of a Notary Public and have it notarized
3. Submit $28.00 for each copy you request in the form of a personal check or money order (indicate the
number of copies you would like on the application form).
4. Send the completed application form, the notarized Sworn Statement and your payment to the
mailing address below.
B. If you are requesting a certified Informational Copy (if you do not qualify to receive an Authorized Certified
Copy, see application form):
1. Complete the application form, one for each individual whose birth certificate you are requesting.
NOTE: If the child is adopted, please make the request in the adopted name.
2. Submit $28.00 for each copy you request in the form of a personal check or money order (indicate the
number of copies you would like on the application form).
3. Send the completed application form and your payment to the mailing address listed below.
C. If you wish to submit your order in person at our physical address listed below, the Sworn Statement must
be signed in the presence of an Office of Vital Records staff member (it does not need to be notarized).
NOTE: If no record of the birth is found the $28.00 fee will be retained for searching (as required by
law) and a Certificate of No Record will be issued.
Checks payable to: “San Bernardino County”
Address:
Vital Statistics Section
340 N. Mountain View Ave
San Bernardino, CA 92415-0038
BIRTH
Rev. 01/2014
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