Fillable Printable Florida Affidavit of Birth Form

Florida Affidavit of Birth Form

DH Form 1958 (New 7/03)

AFFIDAVIT TO RELEASE A BIRTH CERTIFICATE

ATTENTION: This form must be completed in the presence of a Notary Public

State of: ___________________________________ County of: __________________________________

AFFIDAVIT TO RELEASE A BIRTH CERTIFICATE

By Law, Birth certificates can be issued only to the registrant (the child named on the record) if of legal age (18) or emancipated, parent,

guardian, or a legal representative of one of these persons or by court order.

NOTE: To obtain and use a Florida birth record under false or fraudulent purpose is a third degree felony, punishable by the terms

and conditions as set forth in Florida Statutes.

BEFORE ME, the undersigned authority, personally appeared ______________________________________________,

(Print Name of Person Giving an Affidavit)

who after being duly sworn and deposes:

My name is ______________________________________. I am authorized by law to receive the birth certificate

(Print Name of Person Giving Affidavit)

of ________________________________________. I am the (check applicable box)

(Print Registrant’s Full Name)

Child named on the birth certificate.

Parent(s) listed on the child’s birth certificate.

Legal guardian of the child named on the birth certificate.

Legal representative of the child or parent named on the birth certificate.

I hereby authorize the Department of Health, Office of Vital Statistics to issue the birth certificate of:

______________________________________

(Print Child’s Full Name)

to ______________________________________

(Print Name of Person Authorized to Receive Birth Certificate)

FURTHER AFFIANT SAYETH NAUGHT

I hereby swear or affirm the above statements are true and correct.

_________________________________________________________

(Signature of person authorized to release Birth Certificate)

Subscribed and sworn to before me this _________ day of _______________________________, 20__________ by

___________________________________________________, who is: ? Personally Known by me or ? Produced

(Print Name of Authorized Individual)

Identification _____________________________________________. My Commission Expires: _______________.

(Type of Identification Produced)

_____________________________________________

(Signature of Notary Public)

________________________________________________

(Print, Type or Stamp Commissioned Name of Notary Public)