WRITTEN APPLICATION FOR UNRESTRICTED CERTIFIED COPY
OF A BIRTH RECORD
PLEASE REVIEW THE INSTRUCTIONS ON THE BACK BEFORE COMPLETING
Birth Certificate Information: Fee: $25.00 per copy Number of copies requested: ___________
1
Name: ______________________________________________________________________________________________
First
Middle
Last
ADOPTED: YES
Date of Birth: ________________________ City of Birth: _______________________
NO
Month, Day, Year
Father’s Name: ________________________________________________________________________________________
First
Middle
Last
Mother’s Maiden Name: _________________________________________________________________________________
First
Middle
Last (Maiden)
Applicant Information (Your name and address):
2
Name: ______________________________________________________________________________________________
First
Middle
Last
Address: _____________________________________________________________________________________________
Number and Street
City
State
Zip Code
Mailing Address: ______________________________________________________________________________________
If different than above
Number and Street
City
State
Zip Code
Telephone Number: (_____)_____________________
Email: ____________________________________________
With Area Code
To obtain an Unrestricted Certified Copy you must be authorized under section 103526 of the Health and Safety
3
Code. Please review the reverse side of this application to determine which section applies and check the
appropriate box below
103526(c)(1)
103526(c)(2)
103526(c)(3)
103526(c)(4)
103526(c)(5)
103526(c)(6)
I, _______________________________ swear under penalty of perjury that I am an authorized person, as
4
Printed Name
defined in California Health and Safety Code Section 103526(c), and am eligible to receive a certified copy of the
birth record identified on this application form. Sworn this ____ day of ______________________, _________,
at __________________________________________
Signature: ___________________________________
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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 Acknowledgement
State of ____________________ County of _________________
On ___________ before me, __________________________, personally appeared _________________________
who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and
acknowledged to me that he/she executed the same in his/her authorized capacity, and that by his/her signature on the instrument
the person, or the entity upon behalf of which the person 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)
Office use only: Receipt # _________________ Paper #_______________________________ Date ___________
Clerk________
Check#_______________
M/O#______________________
Birth written unrestricted app
01/01/14