Application For Certified Copy Of Birth Record - County Of San Bernardino printable pdf download

County of San Bernardino – Department of Public Health

APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD

NOTICE: Orders received by mail must have an attached notarized sworn statement. (See instructions)

The California Health and Safety Code, Section 103526, permits only authorized persons as defined below to receive a certified

Copy of a birth records. Those who are not authorized by law to receive a certified copy will receive an informational certified copy

marked “INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY.” Please indicate whether you would like an

Authorized Certified Copy or a Certified Informational Copy. If the requestor will use the certificate to obtain a driver’s license, state

I.D.card, passport, or apply for insurance coverage, then a Certified copy must be obtained.

The search fee is the same as the fee for Certified copy. Any questions please contact our office at (909) 381-8990.

____________________________________________________________________________________________________

□

I would like a Certified Copy of the record identified on the

I would like a certified Informational Copy. This

application form

document will be printed with a legend on the face

. (In order to receive a Certified Copy, you

of the document that states, “INFORMATIONAL NOT

must indicate your relationship to the person named on the

A VALID DOCUMENT TO ESTABLISH IDENTITY”

application form by selecting from the list below.)

(A Sworn Statement does not need to be provided)

Note: Both documents are Certified copies of the original document on file. With the exception of the legend,

the documents contain the same exact information.

To receive a Certified Copy I am:

□

The registrant or a parent or legal guardian of the registrant.

□

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.

□

A member of a law enforcement agency or a representative of another governmental agency, as provided by law, who is conducting official

business.

□

A child, grandparent, grandchild, sibling, 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.

IF MAILING APPLICATION, ATTACHED SWORN STATEMENT MUST BE NOTARIZED.

APPLICANT INFORMATION (PLEASE PRINT)

Today’s Date

Printed Name

(Person Requesting the Copy/ies)

Telephone Number

(

)

Address – Number, Street

City

State

ZIP Code

Name of Person Receiving Copies, if Different From Above

No. of Copies

Mailing Address for Copies, If Different From Above

City

State

ZIP Code

BIRTH CERTIFICATE INFORMATION

(PLEASE PRINT)

Name on Certificate – Child’s First Name

Child’s Middle Name

Child’s Last Name

Place of Birth – County

City or Town of Birth

Date of Birth – Month, Day, Year (If unknown, enter approximate date of birth)

Sex

Female

Male

Name on Certificate – Father ‘s First Name

Father’s Middle Name

Father’s Last Name

Name on Certificate – Mother’s First Name

Mother’s Middle Name

Mother’s Last Name (Maiden/Birth Name)

BIRTH

Rev 01/14

Application For Certified Copy Of Birth Record - County Of San Bernardino

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