Form Acr 336 - Application For Certified Copy Or Search Of A Birth Record - 2016
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2RIVERSIDE COUNTY
ASSESSOR-COUNTY CLERK-RECORDER
APPLICATION FOR CERTIFIED COPY OR SEARCH OF A BIRTH RECORD
PLEASE REVIEW THE INSTRUCTIONS ON THE BACK BEFORE COMPLETING
BIRTH RECORD or CERTIFICATE OF NO RECORD INFORMATION
FEE $28.00
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______________________________________________________________________
Name _
First
Middle
Last
Date of Birth __________________________________ City of Birth______________________________________
(Must be in Riverside County)
_________________________________________________________
Mother/Father/Parent Name
First
Middle
Last
(Before Marriage/ Domestic Partnership)
_________________________________________________________
Mother/Father/Parent Name
First
Middle
Last
(Before Marriage/ Domestic Partnership)
Is person listed on record adopted or had a legal name change? Y
/ N
Number of Copies____________
I am requesting an AUTHORIZED copy
I am requesting an INFORMATIONAL copy
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If you are requesting an Informational copy, please skip to section
4.
To obtain an Authorized Certified Copy you must check the appropriate box below: I am:
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The person listed on the birth record or a parent or legal guardian of the person listed on the birth certificate. (Legal guardian must provide
documentation.)
I am requesting an AUTHORIZED copy
A child, grandparent, grandchild, sibling, spouse or domestic partner of the person listed on the birth certificate.
A member of a law enforcement agency or representative of a government agency, as provided by law, who is conducting official business.
(Companies representing a government agency must provide authorization from the government agency.)
A person who has a court order to obtain the record, an attorney or licensed adoption agency seeking the birth record in order to comply with
the requirements of Section 3140 or 7603 of the Family Code. (Please include a copy of the court order.)
An attorney representing the person or the person’s estate whose name is listed on the birth certificate or any person or agency empowered
by statute or appointed by a court to act on behalf of the person or the person’s estate.
Appointed rights in a power of attorney, or an executor of the person or the person’s estate whose name is listed on the birth certificate.
(Please include a copy of the power of attorney, or supporting documentation identifying you as an executor.)
Requested by:
Mail/Issue To:
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________________________________________
________________________________________
Name of Person
Name (and Agency Name if Applicable)
________________________________________
________________________________________
Mailing Address
Street Address
________________________________________
________________________________________
City
State
Zip
City
State
Zip
I.D. #
Phone #
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I, _______________________________ declare under penalty of perjury under the laws of State of California, that I
(Print Full Name)
am an authorized person, and am eligible to receive a certified copy of the birth record described in section 3 above.
____________________________________ at ______________________________________
Sworn:
Date (mm/dd/yyyy)
City
State
___________________________________________________________________________
Signature:
(Applicant Signature)
(If ordering in person you must sign in front of the Clerk)
BELOW SECTION FOR OFFICE USE ONLY
Receipt #
Check #
Total $ Due
Amount Paid
LRN
Overage Amount
Cash
Check Debit / Credit
Refund Amount
Counter
Mail
Type of I.D., Identifying Numbers and Exp. Date
Clerks Initials
Do Not Charge Fee, Contact State
NOTE:_____________________________________________________________________
Charge Search Fee, Contact
State or ________________ Searched years from ___________ to ____________ by: ____________
ACR 336 (Rev. 07/2016)
Available in Alternate Formats
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Parent category: Legal