Ca Vital Records Authorization Form printable pdf download

California Vital Records Authorization Form

Instructions:

1. In the box, print the BIRTH name of the person on the certificate and

your relationship to that individual (i.e., if it is you, write “self”. If you are

the parent, write “parent”, etc.).

2. Print and complete the form. Use your CURRENT name on the top line, signature, etc.

3. Sign and date the form in the presence of a public notary.

4. Fax or email back. Fax: (415).

Sworn Statement

I, ___________________________________ swear/affirm under penalty of perjury under the laws of the State of

California, that I am an authorized person, as defined in the California Health and Safety Code Section 103526(c),

and am eligible to receive a certified copy of the birth, death, or marriage record of the following individuals(s).

Name of Person Listed on Certificate

Relationship to Person Listed on Certificate

BirthAuthorized:

Sworn this ______day of________, 20____ at ___________________,________

( Day) (Month) (City) (State)

______________________________________________

Signature

Note: If submitting your order online or by fax and requesting an Authorized Birth, Death or Marriage Certificate you must have

your Sworn Statement notarized using the Certificate of Acknowledgment, below.

______________________________________________________________________________________________________________

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.

Certificate of Acknowledgment

State of _________________________)

) ss

County of _________________________)

On________________, before me, ________________________________, NOTARY PUBLIC _ _ , personally

(insert name and title of officer)

appeared, ______________________________________________, who proved to me on the basis of

(insert name of person signing)

satisfactory evidence to be the person(s) whose names(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 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

(NOTARY SEAL)

___________________________________________

Notary Signature

Ca Vital Records Authorization Form