Application For Certified Copy Of Birth Certificate - Tyler, Tx

SMITH COUNTY CLERK

200 E. FERGUSON ST. STE. 300

Vol/Pg/Doc#

Security Paper

Initials

___________

TYLER, TX 75702

___________ ______

Receipt#___________

APPLICATION FOR CERTIFIED COPY OF

BIRTH

CERTIFICATE – FEE $23.00

PLEASE PRINT. WE WILL NEED TO PHOTOCOPY A VALID ID.

CHECK ONE

( ) Standard 8 ½”x 7” ( ) Long 8 ½ x 11” Rural Smith County Only

NAME ON RECORD: __________________________________________________GENDER: ( ) MALE ( ) FEMALE

FIRST

MIDDLE

LAST (MAIDEN)

DATE OF BIRTH: ________________________________ PLACE OF BIRTH

________________________________,TX

MONTH

DAY

YEAR

CITY

COUNTY

TEXAS

FATHER: _______________________________________ MOTHER: __________________________________________

(IF LISTED)

FIRST

MIDDLE

LAST

FIRST

MIDDLE

LAST

(MAIDEN)

APPLICANT’S INFORMATION

___________________________________

: ______________________________

YOUR NAME: _________________

PHONE

FIRST

MIDDLE

LAST (CURRENT)

ADDRESS: ________________________________________________ CITY: ________________ STATE: ________ ZIP: __________

RELATIONSHIP TO PERSON ON RECORD ( )SELF ( )PARENT ( )SIBLING ( )SPOUSE ( )OTHER___________________

BROTHER/SISTER

SPECIFY

REASON FOR OBTAINING RECORD ( )ESTABLISH ID ( )JOB ( )SCHOOL ( )PASSPORT ( )OTHER___________________

SPECIFY

( ) I wish to make a voluntary contribution of $5.00 to promote healthy early childhood by supporting the Texas Home Visitation

Program administered by the Office of Early Childhood Coordination of the Health and Human Services.

X___________________________________________

DATE: _______________________________

SIGNATURE

WITH AN ORIGINAL

REQUESTS BY MAIL

- MAIL THIS APPLICATION, PAYMENT AND PHOTOCOPY OF YOUR VALID ID

NOTARIZED PROOF OF IDENTIFICATION

PER 84

LEGISLATIVE SB 200 ART. 5 TO BE EFFECTIVE 09/01/2015 TO:

Smith County Clerk, Attn. Vitals, 200 E Ferguson, Ste. 300, Tyler, Texas 75702

MAKE CHECK OR MONEY ORDER PAYABLE TO “SMITH COUNTY CLERK”.

PLEASE ENCLOSE A SELF-ADDRESSED STAMPED ENVELOPE FOR RETURN OF CERTIFICATE

PAY BY DEBIT/CREDIT CARD: COMPLETE THE ONE TIME CREDIT/DEBIT CARD AUTHORIZATION FORM ON OUR WEBSITE AND

RETURN WITH THIS APPLICATION.

WARNING:

IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY

MAKING A FALSE STATEMENT ON THIS FORM OR FOR SIGNING A FORM WHICH CONTAINS A FALSE STATEMENT IS 2 TO 10

(

YEARS IMPRISONMENT AND A FINE OF UP TO $10,000.

HEALTH AND SAFETY CODE, CHAPTER 195, SEC. 195.003)

Rev 9/2015

Application For Certified Copy Of Birth Certificate - Tyler, Tx - 2015

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