Notarized Agent Authorization Forsyth County printable pdf download

Notarized Agent Authorization (WALK IN ONLY)

This form is to be filled out only by those entitled to get certified copies per NC general statute (self or direct family member, legal

guardian, etc). If they are not able to come to our office or order copies by mail, they may send an agent of their choosing to pick up their

copy. The agent must bring in this original completed and notarized form, along with their own valid ID to the Forsyth County Register of

Deeds office. This form is not to be used by those not entitled.

Completed forms will be retained by the Forsyth County ROD.

I , ___________________________________________________, the undersigned individual,

(Print your full legal name )

do hereby state that I am entitled under North Carolina General Statute to receive a

certified copy of a Forsyth County vital record for _____________________________________;

(Print full legal name of the person on the record )

_______

Select one [1] record type and add the date of birth, death or marriage:

 Birth on date ____/____/____

 Death on date ____/____/____

 Marriage on date ____/____/____

I further state that I am entitled per NC general statute because I am requesting

(select [1] one )

A) 

My own records showing my name as printed above

B) 

My family records

(specify one relationship type below)

Spouse  Parent  Step-Parent  Child  Step-Child  Brother  Sister  Grandparent  Grandchild

C) 

Information for legal determination of personal or property rights

_________________

(provide proof)

__________________________________________________________________________________

D) 

I am an authorized agent, attorney, or legal guardian/representative of a person listed in A, B or C above and

have attached documentation of my authority.

;

(per NC General Statute 130A-93 and 99)

BEFORE GOING FURTHER; i

f you are not able to prove entitlement and

attach documentation of authority if required, then this form can not be used.

I further state that I will use these records for the purpose of ___________________________

___________________________________________________________________________;

I further state that I am not able to appear in the office of the Register of Deeds; therefore I do

hereby grant permission to ____________________________________________________

(Print full legal name of authorized agent- must match their ID )

to act as my agent for the purpose of obtaining the certified copy for which I am entitled;

I understand that my agent must present their own valid identification at the ROD office;

Finally, I state that I have signed this authorization in the presence of a Notary Public and presented

my valid identification to said notary.

______________________________________

________________

Signature

Date

This form is not valid unless ALL sections are completed. Incomplete forms will not be accepted.

NOTARY STATEMENT

I certify that the undersigned individual 1) personally appeared before me, 2) showed me their identification and

3) signed this document in my presence on the ______

of ___________________

, 20 ___ ___

(day)

(month)

(year)

Official Signature of Notary _________________________________________________

Official Seal

Notary’s printed or typed name _____________________________________, Notary Public

In the county of _____________________ in the state of ______

My commission expires on __________________________

Rev'd 2/1/12 (S\Manual\Vitals\Forms\Agent Auth)

Notarized Agent Authorization Forsyth County

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