Fillable Printable Birth Certificate Order Form - Alameda County

Birth Certificate Order Form - Alameda County

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INSTRUCTIONS TO COMPLETE APPLICATION FOR UNRESTRICTED CERTIFIED COPY

OF A BIRTH RECORD-$30.00 PER COPY in ALAMEDA COUNTY

Birth Certificate Information:

Print or type number of copies requested.

Print or type name of registrant.

Print or type date of birth.

Print or type city of birth.

Print or type mother’s maiden last name.

Applicant Information:

If you ordered online at the Alameda County website, please include the 13-digit Order Confirmation Number.

Print or type name of person ordering copy.

Print or type address where copy is to be sent. Post Office Box is not acceptable.

We may need to contact you regarding your certificate order.

Print or type telephone number of person ordering copy, including area code.

Print or type your email address.

Using the list below check the box next to the code section in Item #3 on the front of this application that authorizes

you to obtain an unrestricted certified copy of a birth record:

103526(c)(2)(A) The registrant or a parent or legal guardian of the registrant. (Legal guardian must provide documentation.)

(Name on birth certificate)

103526(c)(2)(B) 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.)

103526(c)(2)(C) A member of a law enforcement agency or a representative of another governmental agency, as

provided by law, who is conducting official business. (Photo identification or a request on the agency’s letterhead.)

103526(c)(2)(D) A child, grandparent, grandchild, sibling, spouse or domestic partner of the registrant.

103526(c)(2)(E) 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. (Please

include a copy of the power of attorney; documentation identifying you as executor or supporting documentation.)

103526(c)(2)(F) An agent or employee of a funeral establishment who acts within the course and scope of his or her

employment and who orders certified copies of a death certificate on behalf of any individual specified in paragraphs

(1) to (5), inclusive, of subdivision (a) of Section 7100.

DO NOT COMPLETE THIS PART UNTIL YOU ARE IN THE PRESENCE OF THE NOTARY PUBLIC WHO WILL

PREPARE THE CERTIFICATE OF ACKNOWLEDGMENT IN ITEM 5.

Section 103526 of the California Health and Safety Code requires anyone requesting an unrestricted certified copy

of a birth record to complete and sign a sworn statement under penalty of perjury.

Certificate of Acknowledgment

Complete Items 1 to 3 on the front of this application, then take this form to a notary public. Complete and sign the

sworn statement in Item 4 in the presence of the notary public. Request that the notary acknowledge your signature

in the sworn statement in Item 4. Mail the original application, with Sections 4 and 5 completed, and the appropriate

fee, to:

Alameda County Clerk-Recorder For Web and Phone Requests,

1106 Madison Street Fax a Completed and Notarized

Oakland, CA 94607 Statement to:

Telephone: 510.272.6362 Fax: 510.208.9957

J:\RECDOCS\New Clerk-Recorder Form Inventory\2015\Vitals & GB

APPLICATION FOR UNRESTRICTED CERTIFIED COPY

OF A BIRTH CERTIFICATE-$30.00 PER COPY in ALAMEDA COUNTY

Birth Certificate Information (Registrant) Number of copies requested: ___________

Birth Name: ________________________________________________________________________________________

Last First

Date of Birth: _______________________________ City of Birth: _______________________________________________

Month/Day/ Year

Mother’s Maiden Name: ___________________________________________________________________________________

Last

Applicant Information (If ordered online) Confirmation #: ____________________

Last Name: _______________________________________ First Name__________________________________________ _

Home Address: __________________________________________________________________________________________

(P.O. Box not acceptable) Number and Street (APT #) City State Zip Code

Shipping Address: _______________________________________________________________________________________

(If Different than home) Number and Street (APT #) City State Zip Code

Telephone Number: _(_____)________________________ Email Address:__________________________________________

To obtain an Unrestricted Certified Copy the applicant must be authorized under section 103526 of the Health and Safety Code.

Please review and check the appropriate box below:

 The registrant 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 California 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. (Photo identification or a request on the agency’s letterhead.)

 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. (Please include a copy of the power of

attorney; documentation identifying you as executor or supporting documentation.)

 An agent or employee of a funeral establishment who acts within the course and scope of his or her employment and who

orders certified copies of a death certificate on behalf of any individual specified in paragraphs (1) to (5), inclusive, of

subdivision (a) of Section 7100.

I, _____________________________________, swear under penalty of perjury that I am an authorized person, as defined in

(Print Applicant’s Name)

California Health and Safety Code Section 103526 (c), and am eligible to receive a certified copy of the birth record identified

on this application form. Sworn this _______________________ day of ___________________________, 20______________,

at _________________________________________ Signature: ________________________________________________

(City and State)

Acknowledgment

State of ____________________

County of __________________

On _______________________ before me, __________________________________________________, personally appeared

(name and title of the officer)

____________________________ 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 on 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:

_______________________________________________

Signature of Notary Public (Notary Seal)

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.