APPLICATION FOR CERTIFIED COPY OF BIRTH CERTIFICATE
Name of Child
(Registrant)
First
Middle
Last
Father’s
Name:
Mother’s
Name:
Date of Birth:
Month/Date/Year
Place of Birth
City or Town
Name of
Applicant:
First
Middle
Last
Mailing
Address:
Number & Street
City & State
Zip Code
Phone
Home:
Cell:
Number:
Please Check The Appropriate Box:
I am the registrant or a parent or legal guardian
I am a child, grandparent, grandchild, sibling, spouse, or domestic partner
I am a party entitled to receive the certificate as a result of court order, or an attorney or a licensed adoption agency
seeking the birth certificate in order to comply with the requirements of section 3140 or 7603 of the family code.
I am an attorney representing the registrant of the registrants estate or any person or agency empowered by
statute or appointed by a court to act on behalf of the registrant or the registrants estate
I am a member of a law enforcement agency or a representative of another government agency as provided
bylaw who is conducting official business
-OR-
I do not qualify as an authorized requestor and am requesting a Certified Informational Copy only.
I understand this copy will be stamped “Informational, Not a valid document to establish identity”.
I declare under penalty of perjury under the laws of the State of California that the above information is true and correct.
City/State where signed
Signature of Applicant
Date_
If applying by mail, and the applicant is an authorized requestor, the applicant’s signature must be notarized and the
acknowledgement must be attached to this application. No acknowledgement is necessary if requesting a certified
informational copy only.
For Official Use Only
Initial of Clerk Issuing Copy
Date Copy Issued
ID #
Receipt #
Type Issued:
_Certified
Informational
CDL
Other
Certificate #
Order Method:
In Person
Mail
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