Form V01m - Application For A Birth Certificate, Or Letter Of No Record - 2016 Page 2
Download a blank fillable Form V01m - Application For A Birth Certificate, Or Letter Of No Record - 2016 in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form V01m - Application For A Birth Certificate, Or Letter Of No Record - 2016 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2SWORN STATEMENT
I, ______________________________________________, declare under penalty of perjury under the laws of the State of California, that I am
(Print Name)
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 record of the following individual(s):
Number of
Name of Person Listed on Certificate
Applicant’s Relationship to Person Listed on Certificate
Copies
Subscribed to this _______ day of ______________, 20_____, at ________________________________, ________________.
(Day)
(Month)
(Yr)
(City)
(State)
______________________________________________________
(Applicant’s Signature)
Note: If submitting your order by mail and requesting a Certified Copy, you must have your sworn statement notarized using the Certificate of
Acknowledgment below. The notary is only verifying the identity of the person requesting the copy not the relationship to the registrant.
Only one notarization is required even though the requestor may have a different authorized relationship to each being requested, (i.e. Mother on one
request, Registrant on another request, etc.).
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 to the truthfulness, accuracy, or validity of that document.
CERTIFICATE OF ACKNOWLEDGMENT
State of _______________________________ County of _____________________________________________________
On _______________________________ before me, ________________________________________________________, Notary Public,
(Insert name of the officer)
Personally appeared _____________________________________ 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 PENALTY OF PERJURY under the laws of the State of California that
the foregoing paragraph is true and correct.
WITNESS my hand and official seal
Personally Known OR
Produced Identification.
Type of Identification produced _________________________
________________________________________________
NOTARY SIGNATURE
Mail Certificate to:
Name __________________________________________________
Address ________________________________________________
Please mail this request along with your payment (check or money
City, State, Zip ___________________________________________
order payable to San Diego County Recorder) to:
Email __________________________________________________
San Diego Recorder/County Clerk
Phone (______) _________________________________________
Attn: Vital Records
P.O. Box 121750
Number of copies ____________X $28.00 = ___________________
San Diego, CA 92112-1750
V01M (01/01/2016)
Page 2 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form V02m - Application For A Marriage Certificate Letter Confirmation Of Marriage Or Letter Of No Record - 2015
Legal
Application For A Practising Certificate Renewal And Solicitor Membership Of The Law Society Of New South Wales - 2015-2016
Legal
Form Rgd 14a - Application For Computerized Birth Certificate - Republic Of Trinidad And Tobago
Business
Related Categories
Parent category: Legal