"Birth Record Application Form" - Norwalk, California

Birth Record Application Form 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 Norwalk.

Form Details:

  • Released on June 1, 2016;
  • The latest edition currently provided by the California Department of Public Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;

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 "Birth Record Application Form" - Norwalk, California

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COUNTY OF LOS ANGELES Ÿ REGISTRAR-RECORDER/COUNTY CLERK, P.O. BOX 489, NORWALK, CA 90651-0489 (562) 462-2137
APPLICATION FOR BIRTH RECORD
Pursuant to Health and Safety Code 103526, the following individuals are entitled to an AUTHORIZED certified copy of a birth
record:
◈ 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
MAIL REQUESTS FOR AUTHORIZED COPIES MUST BE ACCOMPANIED BY A NOTARIZED CERTIFICATE OF IDENTITY.
"INFORMATIONAL, NOT A
Those who are not authorized may receive an INFORMATIONAL certified copy with the words
VALID DOCUMENT TO ESTABLISH IDENTITY" imprinted across the face of the copy.
WE CAN ONLY PROVIDE COPIES FOR BIRTHS THAT OCCURRED IN LOS ANGELES COUNTY.
c I am requesting an AUTHORIZED copy
CERTIFICATE TYPE:
c I am requesting an INFORMATIONAL copy
Note: c Check box if ADOPTED. Enter adopted name and parents’ information on application.
Please PRINT all information legibly.
NUMBER OF COPIES
FOR RECORDER USE ONLY
Por favor imprima legible toda la informacion.
NUMERO DE COPIAS
Month/Mes
Day/Dia
Year/Año
Date of Birth – Fecha De Nacimiento
File Number
NAME GIVEN AT BIRTH (first, middle, last) – NOMBRE DE NACIMIENTO (primero, segundo, apellido)
Searched
CITY OF BIRTH – CIUDAD DE NACIMENTO
Doubled
BIRTH NAME OF FATHER/PARENT – NOMBRE DE NACIMIENTO DEL PADRE/PADRE
BIRTH NAME OF MOTHER/PARENT – NOMBRE DEL NACIMIENTO DE MADRE/MADRE
RELATIONSHIP TO REGISTRANT (SEE ABOVE) - PARENTESCO CON LA PERSONA REGISTRADA (VEÁSE ARRIBA)
I ____________________________________ certify (or declare) under penalty of perjury under the laws
of the State of California that the foregoing is true and correct.
Date ___________________________
Signature__________________________________________________
DL/ID________________________
Phone Number __________________________
Complete your name and mailing address below. Print legibly.
Escriba abajo su nombre y direccion. Imprima legible.
NAME/NOMBRE
STREET ADDRESS/NUMERO Y CALLE
CITY/CIUDAD
STATE/ESTADO
ZIP/ZONA POSTAL
76A639B Rev. 6/16
COUNTY OF LOS ANGELES Ÿ REGISTRAR-RECORDER/COUNTY CLERK, P.O. BOX 489, NORWALK, CA 90651-0489 (562) 462-2137
APPLICATION FOR BIRTH RECORD
Pursuant to Health and Safety Code 103526, the following individuals are entitled to an AUTHORIZED certified copy of a birth
record:
◈ 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
MAIL REQUESTS FOR AUTHORIZED COPIES MUST BE ACCOMPANIED BY A NOTARIZED CERTIFICATE OF IDENTITY.
"INFORMATIONAL, NOT A
Those who are not authorized may receive an INFORMATIONAL certified copy with the words
VALID DOCUMENT TO ESTABLISH IDENTITY" imprinted across the face of the copy.
WE CAN ONLY PROVIDE COPIES FOR BIRTHS THAT OCCURRED IN LOS ANGELES COUNTY.
c I am requesting an AUTHORIZED copy
CERTIFICATE TYPE:
c I am requesting an INFORMATIONAL copy
Note: c Check box if ADOPTED. Enter adopted name and parents’ information on application.
Please PRINT all information legibly.
NUMBER OF COPIES
FOR RECORDER USE ONLY
Por favor imprima legible toda la informacion.
NUMERO DE COPIAS
Month/Mes
Day/Dia
Year/Año
Date of Birth – Fecha De Nacimiento
File Number
NAME GIVEN AT BIRTH (first, middle, last) – NOMBRE DE NACIMIENTO (primero, segundo, apellido)
Searched
CITY OF BIRTH – CIUDAD DE NACIMENTO
Doubled
BIRTH NAME OF FATHER/PARENT – NOMBRE DE NACIMIENTO DEL PADRE/PADRE
BIRTH NAME OF MOTHER/PARENT – NOMBRE DEL NACIMIENTO DE MADRE/MADRE
RELATIONSHIP TO REGISTRANT (SEE ABOVE) - PARENTESCO CON LA PERSONA REGISTRADA (VEÁSE ARRIBA)
I ____________________________________ certify (or declare) under penalty of perjury under the laws
of the State of California that the foregoing is true and correct.
Date ___________________________
Signature__________________________________________________
DL/ID________________________
Phone Number __________________________
Complete your name and mailing address below. Print legibly.
Escriba abajo su nombre y direccion. Imprima legible.
NAME/NOMBRE
STREET ADDRESS/NUMERO Y CALLE
CITY/CIUDAD
STATE/ESTADO
ZIP/ZONA POSTAL
76A639B Rev. 6/16
SPECIAL NOTICE TO VETERANS
You may be eligible for a free certified copy if you are applying for a veteran’s pension or certain other Veteran’s
Administration benefits.
(Section 6107, Government Code State of California). If qualified, we will mail the certificate to
the Veteran Benefit Agency.
THIS DOES NOT APPLY TO SOCIAL SECURITY AND OTHER CIVILIAN BENEFITS,
EVEN IF YOU ARE A VETERAN.
If you believe you qualify for a free certified copy under these provisions, complete the following affidavit.
I hereby apply for a free certified copy of the record as shown on the reverse side and declare under penalty of
perjury that the free copy is to be furnished to
_______________________________________ in a claim for _________________________________
FEDERAL OR STATE AGENCY
TYPE OF BENEFIT
___________________
________________________________________
_____________________
DATE
SIGNATURE OF VETERAN OR AUTHORIZED AGENT
RELATIONSHIP OF AGENT
NUMBER-STREET
CITY
STATE
ZIP
Note: The free copy issued on this affidavit will bear the following wording:
This certified copy has been issued free of charge on the declaration under penalty of perjury that it is to be used in a claim to
the Federal Government or the State of California for veteran’s benefits.
76A639B Rev. 6/16
CERTIFICATE OF IDENTITY/SWORN STATEMENT
FOR BIRTH, DEATH & PUBLIC MARRIAGE
In accordance with California State Law, the following identifying information is required to obtain a certified copy of a Birth,
Death or Public Marriage Certificate. You must be one of the following to receive an authorized copy of a birth, death or public
marriage record: Individual named on certificate, Parent, Child, Legal guardian/custodian, Grandparent, Grandchild, Sibling,
Spouse/Domestic partner, Attorney for individual/estate of individual or Representative of an adoption agency (birth only),
Funeral director or agent/employee (death only).
This certificate must be signed in the presence of a Notary.
Name(s) on Certificate
Relationship
I,_______________________________________________, declare under penalty of perjury under the laws of the State of
(Print Name)
California, 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 public marriage record for the individual(s) listed above.
Subscribed to the ______ day of __________________ 20_____, at ____________________________, ______________.
(Day)
(Month)
(Year)
(City)
(State)
(Signature)
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.
CERTIFICATE OF ACKNOWLEDGEMENT
STATE OF CALIFORNIA
)
) ss
County of ____________________________ )
On ___________________________, before me _____________________________________________ personally appeared
(Date)
(Insert name and title of officer here)
______________________________________, who proved to me on the basis of satisfactory evidence, to be the person
whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her
authorized capacity, and that by his/her signature on the instrument the person, or the entity upon behalf of which the person
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 SEAL)
___________________________________
NOTARY SIGNATURE
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