Fillable Printable Application for Certified Copy of Birth Record - California

Application for Certified Copy of Birth Record - California

StateofCalifornia–HealthandHumanServicesAgencyCaliforniaDepartmentofPublicHealth

APPLICATIONFORCERTIFIEDCOPYOFBIRTHRECORD

PLEASEREADTHEINSTRUCTIONSONPAGE2BEFORECOMPLETINGTHISAPPLICATION



Aspartofstatewideeffortstopreventidentitytheft,Californialaw(HealthandSafetyCodeSection103526)permitsonlyauthorizedindividualsaslistedon the

applicationtoreceivecertifiedcopiesofbirthrecords.AllotherswillbeissuedCertifiedInformationalCopiesmarkedwiththelegend,“Informational,NotA

ValidDocumentto

EstablishIdentity.”

Pleaseindicatethetypeofcertifiedcopyyouarerequesting:



 IwouldlikeaCertifiedCopy.Thiscopywill establishtheidentityof

theregistrant.(ToreceiveaCertifiedCopyyouMUSTINDICATE

YOURRELATIONSHIPTOTHEREGISTRANTbyselectingfromthelist

belowANDCOMPLETETHEATTACHEDSWORNSTATEMENT

declaringthatyouareeligibletoreceivetheCertified

Copy.The

SwornStatementMUSTBENOTARIZEDiftheapplicationis

submittedbymailunlessyouarealawenforcementorlocalor

stategovernmentalagency.)

IwouldlikeaCertifiedInformationalCopy.Thisdocumentwillbe

printedwithalegendonthefaceofthedocument

thatstates,

“INFORMATIONAL,NOTAVALIDDOCUMENTTOESTABLISHIDENTITY.”



(ASwornStatementdoesnotneedtobeprovided.)

NOTE:Bothdocumentsarecertifiedcopiesoftheoriginaldocumentonfilewithouroffice.Withtheexceptionofthelegendandredactionof

signaturesandSocialSecurityNumber,thedocumentscontainthesameinformation.

Fee:$25percopy(payabletoCDPHVitalRecords).PLEASESUBMITCHECKORMONEYORDER–DONOTSENDCASH

(CDPHcannotbeheldresponsibleforfeespaidincashthatarelost,misdirected,orundelivered).

ToreceiveaCertifiedCopyIam:

Theregistrant(personlistedonthecertificate)oraparentorlegalguardianoftheregistrant.(Legalguardianmustprovidedocumentation.)

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.(Pleaseincludeacopyofthecourtorder.)



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.)

Achild,grandparent,grandchild,brotherorsister,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.

Appointedrightsinapowerofattorney,oranexecutoroftheregistrant’sestate.(Pleaseincludeacopyofthepowerofattorney,or

supportingdocumentationidentifyingyouasexecutor.)

APPLICANTINFORMATION(PLEASEPRINTORTYPE) Today’sDate:

AgencyName(IfApplicable) AgencyCaseNumber InmateIDNumber

PrintNameofApplicant SignatureofApplicant PurposeofRequest

MailingAddress–Number,Street AmountEnclosed–DONOTSENDCASH



$_______Check$______MoneyOrder

NumberofCopies

City

NameofPersonReceivingCopies,ifDifferentfromApplicant

State/Province



ZIPCode MailingAddressforCopies,ifDifferentfromApplicant

DaytimeTelephone(includeareacode)

()



Country City State ZIPCode

BIRTHRECORDINFORMATION(PLEASEPRINTORTYPE)Adopted:NoYes(IfYes,see#4onPage2)

Completetheinformationbelowasshownonthebirthrecord,tothebestofyourknowledge.

FIRSTName MIDDLEName LASTName

CityofBirth(mustbeinCalifornia)



CountyofBirth

DateofBirth–MM/DD/CCYY(Ifunknown,enterapproximatedateofbirth)



Sex

___Female ___Male

Father/ParentFIRSTName



MIDDLEName LASTName(BeforeMarriage/DomesticPartnership)

Mother/ParentFIRSTName



MIDDLEName LASTName(BeforeMarriage/DomesticPartnership)

BIRTH

VS111(01/15)Page1of3

PLEASE ATTACH CHE CK HERE



INFORMATION:



BirthrecordshavebeenmaintainedintheCaliforniaDepartmentofPublic HealthVitalRecordssinceJuly1,1905.



ThenamerequiredonVitalRecords(seeItems1C,6C,7C,9C,and12C)isthenamegivenatbirth,oranamereceivedthrough

adoption,court‐orderednamechange,ornaturalization.AKAs(AlsoKnownAs)andassumednamescannotbeenteredasthelegal

nameonthebirthrecord.



INSTRUCTIONS:



1. 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(personlistedonthecertificate).(Page1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.”



 ConfidentialInformationonBirthRecord:someindividualshavespecialneedsforabirthcertificatethatcontainsthe

confidentialinformationprovidedatthetimethebirthrecordwasprepared.Thisconfidentialinformationmaybeusedto

establishethnicity,toprovidehealthbackground,orforotherpersonalreasons.Forinformationonhow

toobtainabirth

certificatecontainingtheconfidentialinformation,pleaserefertotheBirthRecordsectionofourwebsiteat:

www.cdph.ca.gov.Onlyspecificindividualsmayobtainconfidentialcopies.



2.  Completeaseparateapplicationforeachbirthrecordrequested.



3. CompletetheApplicantInformationsectiononPage1andprovideyoursignaturewhereindicated.IntheBirthRecord

Informationsection,providealltheinformationyouhaveavailabletoidentifythebirthrecord.Iftheinformationyou

furnishisincompleteorinaccurate,wemaynotbeabletolocatetherecord.



4. Iftheregistranthasbeenadopted,maketherequestintheadoptedname.IftheregistrantwasbornoutsidetheUnited

Statesandre‐adoptedinCalifornia,markthe“Yes”boxandcompletetheapplicationwiththeadoptedinformation.(Ifyou

arerequestingacopyoftheoriginal

birthcertificate,youmustprovideacourtorderreleasingtheoriginalsealedrecord.)



5. 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–therelationshipmustbeoneofthose

identifiedonPage1.

 Iftheapplicationisbeingsubmittedbymail,theSwornStatementmustbenotarizedbyaNotaryPublic.(Tofinda

NotaryPublic,seeyourlocalyellowpagesorcallyourbankinginstitution.)Lawenforcementandlocalandstate

governmentalagenciesareexemptfromthenotary

requirement.

 YoudonothavetoprovideaSwornStatementifyouarerequestingaCertifiedInformationalCopyofthebirth

record.



6. Submit$25foreachcopyrequested.Ifnobirthrecordisfound,thefeewillberetainedforsearchingfortherecord(as

requiredbylaw)anda“CertificateofNoPublicRecord”willbeissuedtotheapplicant.Indicatethenumberofcopiesyou

wantandincludethecorrect

fee(s)intheformofapersonalcheckorpostalorbankmoneyorder(InternationalMoney

Orderforout‐of‐countryrequests)madepayabletoCDPHVitalRecords.PLEASESUBMITCHECKORMONEYORDER–DO

NOTSENDCASH(CDPHcannotbeheldresponsibleforfeespaidincashthat

arelost,misdirected,orundelivered).



7. Mailcompletedapplicationswiththefee(s)to:



CaliforniaDepartmentofPublicHealth

VitalRecords–MS5103

P.O.Box997410

Sacramento,CA95899‐7410

(916)445‐2684



BIRTH

Page2of3

VS111(01/15)

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an d 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):



NameofPersonListedonCertificate

Applicant’sRelationshipto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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VS111(01/15)

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