Application For Birth Certificate Form - The County Of Nevada, California
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1
2The County Of Nevada
CLERK RECORDER-REGISTRAR OF VOTERS
GREGORY J. DIAZ
950 Maidu Ave Suite 210, Nevada City, CA 95959
• Recorder (530) 265-1221
• Fax (530) 265-9842
950 Maidu Ave Suite 210, Nevada City, CA 95959
• Elections (530) 265-1298
• Fax (530) 265-9829
APPLICATION FOR BIRTH CERTIFICATE
IF A SEARCH RESULTS IN NO RECORD FOUND, THE CUSTOMER WILL BE CHARGED THE COST OF THE SEARCH AND A
CERTIFICATE OF NO RECORD WILL BE ISSUED.
(PURSUANT TO GOVERNMENT CODE 27369 AND HEALTH & SAFETY CODE 103650).
Authorized Certified Copy:
Informational Certified Copy:
To P rove I dentity
Complete Section 1 and 2
Complete Section 1
(For Driver’s License, Passport and School
(Informational is not a valid document to establish identity)
Registration, Etc.)
(See back of form for details)
(Mail orders MUST be notarized-see back of form)
SECTION 1: COMPLETE FOR BOTH INFORMATIONAL OR AUTHORIZED CERTIFIED COPY
Name on Certificate:
First
Middle
Last
x $25.00 per copy
Date of Birth:
City of Birth:
Number of Copies:
Parent’s Name at Parent’s Birth:
Parent’s Name at Parent’s Birth:
Name of Person Requesting Record: (Your Name)
Mailing Address:
City:
State:
Zip:
Phone:
E-mail:
Fax:
(Optional)
Today’s Date:
Driver’s License/ID:
SECTION 2: COMPLETE FOR AUTHORIZED CERTIFIED COPY
Relationship to Name on Certificate:
Self
(Name on Certificate)
Grandparent/Grandchild
Parent/Legal Guardian
Attorney of Record
Spouse/Domestic Partner
Law Enforcement/Government Agency
Sibling
Authorized by way of Court Order
Child
Licensed Adoption Agency
I, the undersigned applicant, declare under penalty of perjury under the laws of the State of California that 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 record identified on
this application form.
Sworn on this date _______________, 20_____ in ___________________________________
(City, State)
Signature___________________________________________________________________________
DATE: _______________ BK/PG: ________________ CERT# ____________________ CLERK INITIALS: ________
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