Form Acr 336 - Application For Certified Copy Or Search Of A Birth Record

INSTRUCTIONS FOR APPLICATION OF

A CERTIFIED COPY OF BIRTH RECORD

If no record of the birth is found, pursuant to Health and Safety Code 103650, the $28.00 fee will be

retained for searching and a Certificate of No Record will be issued.

PLEASE PRINT IN BLACK OR BLUE INK

Birth Certificate Information:

Give all the information you have available for the identification of the record. Riverside County only has birth records that

occurred in Riverside County, with the exception of Court Order Delayed Birth Registrations. For all other birth records you

must contact the county in which the birth occurred or contact the Department of Health Services, Office of Vital Records-

M.S. 5103, P.O. Box 997410, Sacramento, CA 95899-7410. Phone number: (916) 445-2684.

Section 103526 of the California Health and Safety Code restricts who is allowed to obtain an authorized certified copy of a

birth record. You must be one of the authorized persons described in the five sentences in section 3 on the front of this

application.

Those who are not authorized will receive an INFORMATIONAL CERTIFIED COPY with the words “INFORMATIONAL,

NOT A VALID DOCUMENT TO ESTABLISH IDENTITY” imprinted across the face of the copy.

An AUTHORIZED

CERTIFIED COPY of a birth record is required to obtain a driver’s license, passport, social security card and any other

services related to an individual’s identity. If you are requesting an informational copy you do not need to complete the

sworn statement at the bottom of this application.

If you are requesting an authorized certified copy of a birth record, please check the box that allows you to obtain the

authorized certified copy.

Print or type name of person ordering copy.

Print or type physical address of person ordering copy.

A governmental issued picture I.D. is required if ordering in-person. Please have it ready.

Section 103526 of the California Health and Safety Code requires anyone requesting an authorized certified copy of a birth

record to complete and sign the sworn statement on the front of this application. Please print your name in the space

provided, complete the space for the date and location for when and where you sign this statement.

BY MAIL:

When submitting multiple certificate requests at the same time, all requests must contain the completed sworn

statement on the front of this application but only one request would require the notary statement.

Any member of a law enforcement agency or a representative of a state or local government agency, as provided by law, who

applies for a birth certificate conducting official business, is NOT required to provide the notarized statement below.

(a) For an AUTHORIZED copy, complete the sworn statement in front of a notary public.

(b) For an INFORMATIONAL copy, the sworn statement in section 5 on the front of this application and the notarized statement below

are NOT required.

Send the application and a check payable to Riverside County Recorder, P.O. Box 751, Riverside, CA 92502-0751

Certificate of Acknowledgment

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

the truthfulness, accuracy, or validity of that document.

STATE OF CALIFORNIA

}

COUNTY OF _______________________}

On ______________ before me, _____________________________________________________, personally appeared

(Date)

(Print Name and Title of Official)

_______________________________________________________________________________________________ ,

(

)

Insert name of person being acknowledged

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

_____________________________________________

Signature

(Seal)

(Officer signature)

ACR 336 (Rev. 07/2016)

Available in Alternate Formats

Form Acr 336 - Application For Certified Copy Or Search Of A Birth Record - 2016 Page 2

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