Application For Certified Copy Of Birth Record - County Of San Bernardino (Page 2 of 3) in pdf

Application For Certified Copy Of Birth Record - County Of San Bernardino Page 2

County of San Bernardino – Department of Public Health

SWORN STATEMENT

(The Applicant must complete in the presence of a Notary or Vital Records Staff.)

I, ____________________________, declare under penalty of perjury under the laws of the State of California, that

(Applicant’s Printed Name)

I am an authorized person, as defined in California Health and Safety Code Section 103526 (c), and am eligible to receive a certified

copy of the birth or death record of the following individual(s):

Applicant’s Relationship to Person Listed on Certifcate

Name of Person Listed on Certificate (Registrant)

(Must be a Relationship Listed on Page 1 of Application)

Subscribed to this _______ day of ____________, 20______, at _________________________, _________________.

(Day)

(Month)

(City)

(State)

______________________________________________________

(Applicant’s Signature)

Note: If submitting your order by mail, you must have your Sworn Statement notarized using the Certificate of

Acknowledgement below. The Certificate of Acknowledgement must be completed by a Notary Public.

(Law enforcement and local and state governmental agencies are exempt from the notary requirement.)

CERTIFICATE OF ACKNOWLEDGEMENT

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.

State of _________________________)

County of _______________________)

On __________before me, ______________________________, personally appeared ____________________________,

(insert name and title of officer)

who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me

that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity

upon behalf of which the person(s) acted, executed the instrument. I certify under the PENALTY OF PERJURY under the laws of the State of California the

foregoing paragraph is true and correct.

WITNESS my hand and official seal.

(SEAL)

__________________________________________

SIGNATURE OF NOTARY PUBLIC

(January 1, 2015)