Form V01m - Application For A Birth Certificate, Or Letter Of No Record - 2016
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1
2FOR OFFICIAL USE ONLY
COUNTY OF SAN DIEGO
ERNEST J. DRONENBURG, JR.
ASSESSOR/RECORDER/COUNTY CLERK
BY MAIL
APPLICATION FOR A BIRTH CERTIFICATE, OR
LETTER OF NO RECORD
$28.00
– PER COPY
FEES NON-REFUNDABLE
Per California State Law, Health and Safety Code, Section 103526(c), permits only
FOR OFFICIAL USE ONLY
authorized persons as defined below to receive certified copies of Birth Records.
Type of identification provided, if processed in person:
Those who are not authorized by Law to request a certified copy will receive a
Driver’s License
Military ID
certified informational copy marked “INFORMATIONAL, NOT A VALID DOCUMENT
Passport
Other ____________
TO ESTABLISH IDENTITY.”
If we cannot identify the record based on the information you provided, State Law requires that we retain the fee and issue a “Letter of No Record”.
Please wait 3 weeks from the date of the event before submitting your request. You will be asked to present a valid photo ID for all in-person requests.
I would like a Certified Copy of the record identified on the application
I would like a certified Informational Copy of the record identified
form. (In order to receive a Certified Copy, you must indicate your
on the application form. (You are not required to select from the
relationship to the person named on the application form by selecting
list below or complete the statement of identity in order to receive
from the list below.)
an Informational Copy.)
I am:
The registrant (person named on certificate) 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 requirement 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.
BIRTH INFORMATION ON CERTIFICATE (PLEASE PRINT OR TYPE) - $28.00 for each certified copy
First Name
Middle Name
Last Name
Date of Birth
County of Birth
Full Birth Name (First Middle Last) of Birth Mother/Parent Giving Birth
No. of Copies
BIRTH INFORMATION ON CERTIFICATE (PLEASE PRINT OR TYPE) - $28.00 for each certified copy
First Name
Middle Name
Last Name
Date of Birth
County of Birth
Full Birth Name (First Middle Last) of Birth Mother/Parent Giving Birth
No. of Copies
BIRTH INFORMATION ON CERTIFICATE (PLEASE PRINT OR TYPE) - $28.00 for each certified copy
First Name
Middle Name
Last Name
Date of Birth
County of Birth
Full Birth Name (First Middle Last) of Birth Mother/Parent Giving Birth
No. of Copies
Note: The Statement of Identity must accompany this request in our office before a certificate can be issued.
Requestor’s Name _______________________________________________________________________
PLEASE PRINT
V01M (01/01/2016)
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