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W
A
F
U
RITTEN
PPLICATION
OR
NRESTRICTED
C
C
B
R
ERTIFIED
OPY OF A
IRTH
ECORD
$32.00 general public or $19.00 government agencies only
Please review the instructions on the back before completing
Number of copies requested
1
Name:
First
Middle
Last
Date of Birth:
City of Birth:
Month
Day
Year
Father/Parent Name:
First
Middle
Last
Mother/Parent Maiden Name:
First
Middle
Last
Adoption (Circle one) Yes
No
Applicant Information
2
Name:
First
Middle
Last
Address
Number and Street
City
State
Zip Code
Mailing Address:
(If different from above) Number and Street
City
State
Zip Code
Telephone Number:
(
)
(with area code)
To obtain an Unrestricted Certified Copy you must be authorized under section 103526 of the Health and
3
Safety Code. Please review the reverse side of this application to determine which section applies and
check the appropriate box below.
103526(c)(2)(A)
103526(c)(2)(B)
103526(c)(2)(C)
103526(c)(2)(E)
103526(c)(2)(F)
103526(b)(1)(info copy)
103526(c)(2)(D)
I
swear under penalty of perjury that I am an authorized person,
4
(printed name)
as 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:
(City)
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to
5
which this certificate is attached, and not the truthfulness, accuracy or validity of that document.
Certificate of Acknowledgment
State of
County of
Notary public
On
before me,
, personally appeared
,
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)
Office Use Only:
Reel/Image
Paper#
Deputy
Birth written unrestricted app
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