Form VS111 "Application for Certified Copy of Birth Record" - County of Sonoma, California

Form vs111 or the "Application For Certified Copy Of Birth Record - Sonoma County" is a form issued by the California Department of Public Health.

The form was last revised in January 1, 2013 and is available for digital filing. Download an up-to-date fillable Form vs111 in PDF-format down below or look it up on the California Department of Public Health Forms website.

ADVERTISEMENT

Download Form VS111 "Application for Certified Copy of Birth Record" - County of Sonoma, California

730 times
Rate
4.8(4.8 / 5) 49 votes
Sonoma County Clerk’s Office
Vital Records Division
APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD
In an attempt to stop the illegal use of vital records, and as part of statewide efforts to reduce identity theft, a new law (effective July 1, 2003)
changed the way certified copies of birth certificates are issued. Certified Copies to establish the identity of a registrant can be issued only to
authorized individuals, as indicated below. All others will be issued Certified Informational Copies that are not valid to establish identity.
Fees: $23 per copy (payable to the Sonoma County Clerk).
Please indicate the type of certified copy you are requesting:
o
o
I would like a Certified Copy. This copy will establish the identity
I would like a Certified Informational Copy. This
of the registrant. (To receive a Certified Copy you must indicate
document will be printed with a legend on the face of
your relationship to the registrant by selecting from the list below
the document that states, “INFORMATIONAL, NOT
AND complete the attached Sworn Statement declaring that you
A VALID DOCUMENT TO ESTABLISH IDENTITY.”
are eligible to receive the Certified Copy. Your signature on the
(A sworn statement does not need to be provided.)
Sworn Statement must be acknowledged by a Notary Public if the
application is submitted by mail or fax.)
NOTE: Both documents are certified copies of the original document on file with our office. With the exception of the legend, the
documents contain the exact same information.
To receive a Certified Copy I am:
o
The registrant (person listed on the certificate) or a parent or legal guardian of the registrant.
o
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.
o
A member of a law enforcement agency or a representative of another governmental agency, as provided by law, who is conducting
official business. (Companies representing a government agency must provide authorization from the government agency.)
o
A child, grandparent, grandchild, sibling, spouse, or domestic partner of the registrant.
o
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 you are requesting a Certified Copy under a power of attorney, please
include a copy of the power of attorney with this application form.)
DO NOT complete the rest of this form before reading the detailed instructions on Page 3.
APPLICANT INFORMATION
(PLEASE PRINT OR TYPE)
Printed Name and Signature of Person Completing Application
Today’s Date
Telephone Number – Area Code First
(
)
Address – Number, Street
City
State
ZIP Code
Name of Person Receiving Copies, if Different From Above
No. of Copies
Amount Enclosed
Purpose of Request
Mailing Address for Copies, If Different From Above
City
State
ZIP Code
BIRTH CERTIFICATE INFORMATION
(PLEASE PRINT OR TYPE)
Name on Certificate – First Name
Name on Certificate – Middle Name
Name on Certificate – Last Name
City or Town of Birth
Place of Birth – County
Sex
Date of Birth – Month, Day, Year (If unknown, enter approximate date of birth)
Female
Male
Name on Certificate – Father‘s First Name
Name on Certificate – Father’s Middle Name
Name on Certificate – Father’s Last Name
Name on Certificate – Mother’s First Name
Name on Certificate – Mother’s Middle Name
Name on Certificate – Mother’s Maiden Name
BIRTH
VS 111 (01/01/13)
Page 1 of 3
Sonoma County Clerk’s Office
Vital Records Division
APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD
In an attempt to stop the illegal use of vital records, and as part of statewide efforts to reduce identity theft, a new law (effective July 1, 2003)
changed the way certified copies of birth certificates are issued. Certified Copies to establish the identity of a registrant can be issued only to
authorized individuals, as indicated below. All others will be issued Certified Informational Copies that are not valid to establish identity.
Fees: $23 per copy (payable to the Sonoma County Clerk).
Please indicate the type of certified copy you are requesting:
o
o
I would like a Certified Copy. This copy will establish the identity
I would like a Certified Informational Copy. This
of the registrant. (To receive a Certified Copy you must indicate
document will be printed with a legend on the face of
your relationship to the registrant by selecting from the list below
the document that states, “INFORMATIONAL, NOT
AND complete the attached Sworn Statement declaring that you
A VALID DOCUMENT TO ESTABLISH IDENTITY.”
are eligible to receive the Certified Copy. Your signature on the
(A sworn statement does not need to be provided.)
Sworn Statement must be acknowledged by a Notary Public if the
application is submitted by mail or fax.)
NOTE: Both documents are certified copies of the original document on file with our office. With the exception of the legend, the
documents contain the exact same information.
To receive a Certified Copy I am:
o
The registrant (person listed on the certificate) or a parent or legal guardian of the registrant.
o
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.
o
A member of a law enforcement agency or a representative of another governmental agency, as provided by law, who is conducting
official business. (Companies representing a government agency must provide authorization from the government agency.)
o
A child, grandparent, grandchild, sibling, spouse, or domestic partner of the registrant.
o
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 you are requesting a Certified Copy under a power of attorney, please
include a copy of the power of attorney with this application form.)
DO NOT complete the rest of this form before reading the detailed instructions on Page 3.
APPLICANT INFORMATION
(PLEASE PRINT OR TYPE)
Printed Name and Signature of Person Completing Application
Today’s Date
Telephone Number – Area Code First
(
)
Address – Number, Street
City
State
ZIP Code
Name of Person Receiving Copies, if Different From Above
No. of Copies
Amount Enclosed
Purpose of Request
Mailing Address for Copies, If Different From Above
City
State
ZIP Code
BIRTH CERTIFICATE INFORMATION
(PLEASE PRINT OR TYPE)
Name on Certificate – First Name
Name on Certificate – Middle Name
Name on Certificate – Last Name
City or Town of Birth
Place of Birth – County
Sex
Date of Birth – Month, Day, Year (If unknown, enter approximate date of birth)
Female
Male
Name on Certificate – Father‘s First Name
Name on Certificate – Father’s Middle Name
Name on Certificate – Father’s Last Name
Name on Certificate – Mother’s First Name
Name on Certificate – Mother’s Middle Name
Name on Certificate – Mother’s Maiden Name
BIRTH
VS 111 (01/01/13)
Page 1 of 3
Sonoma County Clerk
Vital
Records Division
SWORN STATEMENT
(*Required for certified copy of record. This Sworn Statement is not required when requesting
an Informational certified copy which is not valid to establish identity)
*Any member of a law enforcement agency or a representative of a state or local government agency, as provided
by law, who orders a copy of a record to which subdivision (a) applies in conducting official business must
complete the Sworn Statement, however, they may not be required to have their signature on the Sworn Statement
acknowledged by a Notary Public.
I,
__
_______________________________
, declare under penalty of perjury under the laws of the State of California,
(Pr inted 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 record of the following individual(s):
Name of Person Listed on the Birth Certificate
Your Relationship to the Person Listed on the Birth Certificate
(The remaining information must be completed in the presence of a Notary Public or County Clerk staff.)
Subscribed to this _
______
day of
______________
, 20
___
, at
________________________
_,
________________.
(Da
y)
(Month)
(City)
(State)
___
___________________________________________________
(Signature of person requesting certified copy)
Note: If submitting your order by mail or fax, you must have your signature on the Sworn Statement
acknowledged by a Notary Public using the Certificate of Acknowledgment below. If submitting your order in
person, you must sign this in the presence of County Clerk staff.
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
CERTIFICATE OF ACKNOWLEDGMENT
State of _
___________________)
) ss
County of
__________________
_)
On ________________, before me, _______________________________________________________________, personally
(Insert your name and title)
appeared __________________________________________________________________________, who proved to me on the
basis of satisfactory evidence to be the person(s) whose name 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.
(NOTARY S AL)
E
_____________________________________________________
NOTARY SIGNATURE
Page 2 of 3
VS 111 (01/01/13)
INSTRUCTIONS:
1.
As of July 1, 2003, ONLY individuals who are authorized by Health and Safety Code Section 103526
can obtain a Certified Copy of a Birth Record to establish identity of the registrant. (Page 1 of the
application identifies the individuals who are authorized to make the request.) All others may receive a
Certified Informational Copy which will be marked, “Informational, Not a Valid Document to Establish
Identity.”
2.
Complete a separate application form for each record of birth requested.
3. Complete
the Applicant Information section on the first page of this form and provide your signature
where indicated. Provide all the information you have available to identify the record of the registrant
under Birth Certificate Information. If the information you furnish is incomplete or inaccurate, it may
be impossible to locate the record. If the registrant has been adopted, please make the request in
the adopted name, and submit your request and fee directly to the Office of Vital Records,
Attention Certified Copies, MS 5103, PO Box 997410 Sacramento 95899-7410.
4. SWORN
STATEMENT:
The authorized individual requesting the certified copy must sign the attached Sworn Statement,
declaring, under penalty of perjury, that they are eligible to receive the certified copy of the birth
record and identify their relationship to the registrant.
If the application is being submitted by mail or fax, your signature on the Sworn Statement must
be acknowledged by a Notary Public. (To locate a Notary Public, see your local yellow pages or
call your banking institution.).
Any member of a law enforcement agency or a representative of a state or local government agency, as
provided by law, who orders a copy of a record to which subdivision (a) applies in conducting official
business is required to complete the Sworn Statement, however, they may not be required to have their
signature on the Sworn Statement acknowledged by a Notary Public.
If the application is being submitted in person at the County Clerk’s Office, the Sworn Statement
must be signed by you in the presence of County Clerk staff, and your signature does not
have to be acknowledged by a Notary Public. You must also provide valid photo
identification to the County Clerk staff at the time you apply for the copy.
A Sworn Statement does not need to be provided if you are requesting a Certified Informational
Copy of the birth record.
5. Submit $23 for each certified copy requested. If no record of the birth is found, the $23 fee will be
retained for searching the record (as required by law) and a Certificate of No Public Record will be issued
to the applicant. Indicate the number of certified copies you wish and include the correct fee(s) in the
form of a personal check, postal or bank money order (International Money Order for out-of-country
requests) made payable to the Sonoma County Clerk. Mail this application with the fee(s) and a self-
addressed stamped envelope to:
Vital Records Division
Sonoma County Clerk
2300 County Center Dr Ste B177
Santa Rosa CA 95403
6.
Credit card orders may be processed on-line at
www.vitalchek.com
Additional costs apply for
processing orders using a credit card. Please follow the directions on Vitalchek’s website if ordering
using a credit card.
Sonoma County Clerk
2300 County Center Dr Ste B177
Santa Rosa CA 95403
707-565-2645 (phone)
707-565-3957 (fax)
BIRTH
Page 3 of 3
VS 111 (01/01/13)
ADVERTISEMENT
Fill PDF online
Page of 3