Application For Birth Certificate Form - Kerr County
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1Jannett Pieper,
Kerr County Clerk
For Office Use Only
For Office Use Only
700 Main St, #122
Cert. #____________
Remit No. _____________
DOCUMENT CONTROL#
Amount $______________
Kerrville, Texas 78028
________________________
Cash
Check
Tel: (830) 792-2255
Date: _________ By: _______
Fax: (830) 792-2274
By: __________
jpieper@co.kerr.tx.us
Application for Birth Certificate
BIRTH
DONATION
Yes,
Amount Requested
I wish to make a voluntary contribution
_____ Certified Copies @ $23.00
of $5 to promote healthy early childhood
each.
by supporting the Texas Home Visiting
PLEASE PRINT
Program.
1. Full Name of
First Name
Middle Name
Last Name
Person on Record
2. Date of
Month
Day
Year
3. Sex
Birth or Death
4. Place of
City or Town
County
State
Birth or Death
5. Full Name
First Name
Middle Name
Last name
of Father
6. Full Maiden
First Name
Middle Name
Maiden Name
Name of Mother
7. Your Name:
_________________________________ 8. Telephone: (
) ______________
(person filing out the form)
9. Your Mailing Address: ______________________________ City: ___________________State/Zip: _____________
10. Relationship to person named in Item 1 above: _________________________________________________________
11. Purpose for obtaining this record: ___________________________________________________________________
For any search of the files where a record is NOT found, the search fee is non-refundable or transferable.
WARNING: THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT ON THIS FORM CAN BE 2-10
YEARS IN PRISON AND A FINE OF UP TO $10,000. (HEALTH AND SAFETY CODE, CHAPTER 195, SEC 195.003)
Birth records are confidential for 75 years and Death records are confidential for 25 years, therefore, issuance is restricted. Other
records may be obtained when sufficient information for identification is provided.
Administrative rules require that on restricted records, all identifying information in Items 1-5 and 10 -11 must be provided in order to
issue such record being requested along with a Xerox copy of the identification from the person requesting the record.
Your Signature: _____________________________
Date of Application: _______________________________
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