Ca Vital Records Authorization Form (Page 2 of 2) in pdf

AUTHORIZATION FORM SAMPLE (THIS IS JUST FOR YOUR REFERENCE)

Common Error Checklist

Make sure to list the person’s birth name and your relationship to that person in the box

Make sure the dates on the top and bottom portion match

Make sure the notary uses an ink stamp and lists his or her notary expiration date.

Sworn Statement

J ohn Sample

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

J ohn Sample

S elf

BirthAuthorized:

1 0th

1 5

H ouston

T X

5 th

Sworn this __

_ _day of

_ , 20_

_ _ at ___

_ __________,__

_ ___

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

J ohn Sample

_ _ _____________

________

S ignature

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

T exas

State of ____

_ _____________)

) ss

H arris

County of ______

_ ____________)

1 0/5/15

J ennifer Notary

On____

_ _____, before me, __

_ ______________, NOTARY PUBLIC _ _ , personally

(insert name and title of officer)

J ohn Sample

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

J ennifer Notary

____________

_ ________ (NOTARY SEAL)

Notary Signature

Jennifer Notary

N otary Public, State of Texas

☆

My Commision Expires 3/3/18

Ca Vital Records Authorization Form Page 2

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