Vital Records Application Form - Texas

This "Vital Records Application Form" is a document issued by the Texas Health and Human Services specifically for Texas residents with its latest version released on July 1, 2014.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Texas Health and Human Services.

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City of Yoakum Local Registrar
Vital Records Application Form
PO Box 738/808 Hwy 77A South
Revised July 2014
Yoakum, TX 77995
Phone #: (361) 293-6321 Fax #: (361) 293-3318
Instructions:
Read ALL instructions carefully before completing and submitting this application.
If any relevant part of this application is left blank, it will be returned to you.
Valid identification must be presented
to verify you are a qualified applicant
(a copy will be made)
.
A LONG FORM BIRTH CERTIFICATE is recommended if applying for a PASSPORT.
Birth records are confidential for 75 years from the date of birth; therefore, issuance is restricted to a qualified applicant
ONLY.
Death records are confidential for 25 years from the date of death; therefore, issuance is restricted to a qualified applicant
ONLY.
PLEASE PRINT
Applicant’s Information
:
(this is you)
Your Name:
Phone #:
Relationship To Individual on
Record:
Address (Mailing/Physical):
City:
State:
Zip:
Reason For Obtaining A Copy of This Record:
Your Signature:
Date:
WARNING: It is a felony to falsify information on this document. The penalty for knowingly making a false statement on this form or for signing this form which contains
a false statement can result in 2-10 years in prison and a fine of up to $10,000 (Health & Safety Code, Chapter 678, Sec.195.003)
Record
:
(information on certificate)
Name on Record:
Date of Birth/Death:
Sex:
☐ Male
☐ Female
City & County of Birth/Death:
For Death – Date of Birth:
For Death – Place of Birth:
Mother’s First Name:
Middle:
MAIDEN
Last
Father’s First Name:
Middle
Last
(IF listed)
What are you applying for
?
(please check box below)
Birth Certificate
☐ Abstract/Short Form OR ☐ Long
)
Form
(born in YOAKUM - 1947 to present ONLY
$23.00 x #________copies = $________
We accept Check, Cash, Money Order, Visa or Mastercard - please add
3.2% additional cost for processing of a debit/credit card.
OR
($23.74 if by credit/debit card)
Fee rates are set by the Texas Board of Health and are not mandated by the Texas
Legislature. For any search where a record is not found, the search fee is NOT
Death Certificate
(died in Yoakum – 1948 to present ONLY)
refundable or transferrable.
st
$21.00 – 1
Copy
+
($21.67 if by credit/debit card)
$3.00 x #________ additional copies = $________
($3.10 if by credit/debit card)
(Death certificates obtained at a different date/time will accrue a new fee of $21.00)
If mailing & paying by credit/debit card:
MUST PRESENT VALID IDENTIFICATION & SUBMIT PAYMENT
Name on Card:_______________________
BEFORE APPLICATION IS PROCESSED.
Card #:_____________________________
Signature:__________________________
It is recommended that vital records be mailed to you via a traceable method
Expiration Date:_____________________
(certified mail, UPS, FedEx) - additional fees will apply, please call our office.
.
FOR OFFICE USE ONLY:
Identification Type:__________________________________Document #:________________________Expiration:____________
Other identification, if required:_______________________________________________________________________________
OBTAIN COPY OF ALL ID/DOCUMENTATION PROVIDED
Local Registrar/State File #:____________________  Birth Certificate Abstract/Short Form  Long Form
 Death Certificate
Type of Payment:  Cash  Check #_________  Money Order  Credit Card – Mastercard OR Visa
City of Yoakum Local Registrar
Vital Records Application Form
PO Box 738/808 Hwy 77A South
Revised July 2014
Yoakum, TX 77995
Phone #: (361) 293-6321 Fax #: (361) 293-3318
Instructions:
Read ALL instructions carefully before completing and submitting this application.
If any relevant part of this application is left blank, it will be returned to you.
Valid identification must be presented
to verify you are a qualified applicant
(a copy will be made)
.
A LONG FORM BIRTH CERTIFICATE is recommended if applying for a PASSPORT.
Birth records are confidential for 75 years from the date of birth; therefore, issuance is restricted to a qualified applicant
ONLY.
Death records are confidential for 25 years from the date of death; therefore, issuance is restricted to a qualified applicant
ONLY.
PLEASE PRINT
Applicant’s Information
:
(this is you)
Your Name:
Phone #:
Relationship To Individual on
Record:
Address (Mailing/Physical):
City:
State:
Zip:
Reason For Obtaining A Copy of This Record:
Your Signature:
Date:
WARNING: It is a felony to falsify information on this document. The penalty for knowingly making a false statement on this form or for signing this form which contains
a false statement can result in 2-10 years in prison and a fine of up to $10,000 (Health & Safety Code, Chapter 678, Sec.195.003)
Record
:
(information on certificate)
Name on Record:
Date of Birth/Death:
Sex:
☐ Male
☐ Female
City & County of Birth/Death:
For Death – Date of Birth:
For Death – Place of Birth:
Mother’s First Name:
Middle:
MAIDEN
Last
Father’s First Name:
Middle
Last
(IF listed)
What are you applying for
?
(please check box below)
Birth Certificate
☐ Abstract/Short Form OR ☐ Long
)
Form
(born in YOAKUM - 1947 to present ONLY
$23.00 x #________copies = $________
We accept Check, Cash, Money Order, Visa or Mastercard - please add
3.2% additional cost for processing of a debit/credit card.
OR
($23.74 if by credit/debit card)
Fee rates are set by the Texas Board of Health and are not mandated by the Texas
Legislature. For any search where a record is not found, the search fee is NOT
Death Certificate
(died in Yoakum – 1948 to present ONLY)
refundable or transferrable.
st
$21.00 – 1
Copy
+
($21.67 if by credit/debit card)
$3.00 x #________ additional copies = $________
($3.10 if by credit/debit card)
(Death certificates obtained at a different date/time will accrue a new fee of $21.00)
If mailing & paying by credit/debit card:
MUST PRESENT VALID IDENTIFICATION & SUBMIT PAYMENT
Name on Card:_______________________
BEFORE APPLICATION IS PROCESSED.
Card #:_____________________________
Signature:__________________________
It is recommended that vital records be mailed to you via a traceable method
Expiration Date:_____________________
(certified mail, UPS, FedEx) - additional fees will apply, please call our office.
.
FOR OFFICE USE ONLY:
Identification Type:__________________________________Document #:________________________Expiration:____________
Other identification, if required:_______________________________________________________________________________
OBTAIN COPY OF ALL ID/DOCUMENTATION PROVIDED
Local Registrar/State File #:____________________  Birth Certificate Abstract/Short Form  Long Form
 Death Certificate
Type of Payment:  Cash  Check #_________  Money Order  Credit Card – Mastercard OR Visa
Are You A Qualified Applicant?
A properly qualified applicant is defined as the individual themselves OR an immediate family member either by blood,
marriage, or adoption; his or her guardian; or his or her legal agent or representative. Examples of qualified applicants based
on the information stated above are:
Self;
Father (if listed on the record; if NOT listed, must have court order stating he is the Father, otherwise record will
NOT be issued);
Step-Father (must have marriage license/certificate to prove relationship);
Mother;
Step-Mother (must have marriage license to prove relationship, if Father who she is married to is NOT listed on the
record, the record will NOT be issued);
Grandmother (must have their child’s birth certificate to prove relationship);
Grandfather (must have their child’s birth certificate to prove relationship);
Brother (must have their own birth certificate to prove relationship);
Step-Brother (must have parent’s marriage license/certificate and their own birth certificate to prove relationship);
Sister (must have their own birth certificate to prove relationship);
Step-Sister (must have parent’s marriage license/certificate and their own birth certificate to prove relationship);
Husband (must have marriage license/certificate to prove relationship);
Wife (must have marriage license/certificate to prove relationship);
Legal Guardian (must have a copy of the LEGAL guardianship papers);
Legal Representative (must have LEGAL documents proving representation)
If a Father is NOT listed on the individual’s birth certificate, he may NOT obtain a copy unless there is a court order stating
he is the Father. This also applies to Grandparents and other relatives related to the Father.
A note signed by a Mother, Father or other representative giving permission for someone else to pick up the record will be
accepted unless notarized and accompanied by a legible copy the ID of the person writing/signing the statement. The
individual presenting becomes the applicant and will also be required to present his or her ID and any other documentation
necessary.
Local, State, and Federal Law enforcement agencies
and other persons may be designated as properly qualified applicants
by demonstrating direct and tangible interest in the record when the information in the record is necessary to implement a
statutory provision or to protect a personal property right. Quite often the agency cannot completely identify a record. In
this instance, we may only be able to provide a birth/death verification letter.
A Legal Representative
could be an attorney in fact, a funeral director, or any other person designated by affidavit, contract,
or court order acting on behalf and for the benefit of the registrant or his or her immediate family. In order to determine the
need for protection for personal property rights when the legal representative is acting on behalf and for the benefit of the
registrant or the registrant’s immediate family member or other entity having a direct and tangible interest in the record, the
SHALL require a designation document or an attested
State Registrar, Local Registrar, or County Clerk
statement to that affect
[25 TAC § 181.1(17)].
CONFIDENTIALITY OF RECORDS
A person or organization does not have to meet the requirements of a properly qualified applicant to obtain copies of records
that fall outside the confidentiality period (Birth Records for 75 years and Death Records for 25 years) according to the
ALL applicants MUST still complete an application, provide identification, and
Public Information Act.
provide a reason for obtaining the record.
ALL APPLICANTS MUST HAVE A VALID IDENTIFICATION, NO EXCEPTIONS!
We reserve the right to ask for additional identification and/or documents we feel necessary to process a request for a vital
record; and may refuse issuance at any time.
Identification Requirements
If the applicant is unable to present a current form of photo identification, two valid supporting forms of identification must
be presented, one of which bears the applicant’s signature. *25 TAC §181.1(13)
All applicants for certificates must present proof of identity satisfactory. All documents must be verifiable. There are three
categories of documents that may be presented to establish proof of identity. A copy will be made of the identification and
retained with the application.
The acceptability of the identification presented by the customer is at the discretion of the
processor and the Local Registrar.
Primary identification – These items are complete within themselves and require no supporting instruments. All of these
may NOT be expired for more than 90 days and must have photo.
(A)
US Government-issued driver license
(B)
US Government issued Country/State/City/County ID card
(C)
US Current student ID with picture
(D)
US Government employment badge or card
(E)
Private company employment badge or card
(F)
Prison ID/Offender ID card
(G)
US Military ID
(H)
Passport (From Any Country)
(I)
US Citizenship Certificate or Certificate of Naturalization
(J)
Permanent Resident Card (Resident Alien)
(K)
US Department of Homeland Employment authorization Card
(L)
Resident alien card
(M)
US Citizen Identification
(N)
Border Crossing Card (O) Reentry Permit Form
(P)
Refugee Travel Document
(Q)
Concealed Handgun License
(R)
Pilot’s license
(S)
Social Worker employee ID
(2)
Secondary identification – In the absence of a primary form of identification, the secondary identification serves to
establish identity; however, the customer is required to produce either two pieces of secondary identification of different
types, or one piece of secondary identification plus two pieces of support identification of different types. The secondary
identification is classified as government issued documents, documents that require identification to establish, or
documents that contain biometric identifiers.
(A)
Foreign country Government-issued driver license
(B)
Foreign country Government issued Country/State/City/County ID card
(C)
Foreign country Current student ID
(D)
Foreign country Government employment badge or card
(E)
Foreign Government Military ID
(F)
US Current student ID without picture
(G)
Foreign Current student ID
(H)
Any primary ID that is expired for more than 90 days
(I)
An organizational ID
(J)
A photocopy or original signed Social Security card
(K)
Public library card
(L)
Credit card
(M)
Retail club card with picture (such as Costco or Sam’s Club)
(N)
DD-214
(O)
Medicaid card
(P)
VA card
(Q)
Medical insurance card
(R)
Signed federal tax return
(S)
Medical insurance card
(3)
Supporting identification – These items consist of other records or documents that aid examining personnel in
establishing the identity of the applicant. The following items are not all inclusive. The examining or supervisory
personnel may determine that an unlisted document meets the department’s needs in establishing identity.
(A)
Recent utility bill with current address
(B)
Recent paycheck stub
(C)
Recent bank account statement
(D)
Public assistance applications or letters
(E)
Signed valid voter’s registration card
(F)
Police report of stolen identification
(G)
Hospital admission records, immunization records, medical bills.
(H)
Official school transcript
(I)
Bank account statement
(J)
Social Security Letter
(K)
Marriage license
(L)
Divorce decree
(M)
Certified birth certificate from Department of State (FS-240, DS-1350 or FS-545), state other than Texas, District
of Columbia, or other country
(N)
Automobile insurance card
(O)
Lease agreements
(P)
Promissory notes or loan contracts
(Q)
Court order
(R)
Property titles or liens
(S)
Automobile titles
(4)
Every applicant must present:
(A)
One piece of primary identification, or
(B)
Two pieces of secondary identification of different types, or
(C)
One piece of secondary identification plus two pieces of support identification of different types
(5)
Other documents may be presented to enable an otherwise non-qualified applicant capable of obtaining a document for
an individual. Some of these are:
(A)
Notarized authorization form – This is an authorization form signed by the individual authorizing another person
to obtain their documents. The form must be notarized and have a copy of the registrant’s identification attached.
(B)
Foreign court papers that reference an individual may be used to obtain the death certificates for an individual.
Examples of this are wills, probate forms, testamentary letters, property liens and titles, and promissory notes.
(C)
Powers of attorney must either be specific power of attorney authorizing the agent to obtain the documents, or must
be general or durable powers of attorney.
(D)
Documents in a foreign language are acceptable, but must be translated into English. If personnel is not available
that can verify the accuracy of the translation, the documents must be translated by a certified translator (this is the
responsibility of the person requesting the vital record).
(E)
A social worker that is the caseworker for an individual may get their client’s documents for them. They must
present documentation indicating that the registrant is in their care. If the registrant is in the care of an organization
or institution, the documentation must indicate the organization or institution, and the social worker must present
documentation showing they are working on behalf of that organization or institution.
Note: An affidavit must be executed before an official authorized to take oaths or affirmations.
Our office does not accept the Matricula Consular and/or the Mexican Electoral Cards as a form of valid identification
because:
♦ The Mexican consulate that issues the Matricula Consular does not authenticate the documents used to
obtain it. The issuing consulate does not verify the source documents.
♦ The issuing consulate does not compare the documents to computerized data files administered by the
government of the United Mexican States.
♦ The U.S. Immigration and Naturalization Service do not recognize the Matricula Consular as proper
identification.
♦ According to testimony before the U.S. Congress, the Department of Justice and the Federal Bureau of
investigation have concluded that the Martricula Consular is not a reliable form of identification.
♦ The Matricula Consular is issued on the day it is requested, with visual inspection of supporting
documents presented by the 47 Mexican consulates, but no independent verification of the identity of the
requestor.
It is the conclusion of DSHS / VSU that the Martricula Consular identity cards are not secure enough to meet the standards
that this agency requires under the authority vested in it by the statutes of the State of Texas and the administrative rules
adopted to implement them. Therefore, we cannot accept the Matricula Consular as verification of identity for the purchase
of birth or death certificates or for obtaining confidential records.

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