State of California – Health and Human Services Agency
California Department of Public Health
AFFIDAVIT OF HOMELESS STATUS FOR FEE EXEMPT
CERTIFIED COPY OF BIRTH CERTIFICATE
INFORMATION
A fee exempt copy of a birth record may be obtained from the local registrar or
county recorder office in the county where the registrant was born. A fee exempt
copy cannot be obtained from the State Registrar.
Each eligible person may only receive one fee exempt birth record, per application.
Requests for fee exempt copies are still subject to other requirements outlined in the
application for obtaining copies of birth records.
Applications for a certified copy of a birth record may be obtained by contacting the
vital records office in the county where the birth occurred.
Requirements for eligibility to receive a fee exempt copy of a birth certificate:
Requests may be made by a homeless person, child or youth who can verify status
as homeless.
Requests may be made by a homeless person, child, or youth on behalf of
themselves or by any person lawfully entitled to request a certified record of live birth
on behalf of a homeless child or youth.
A “homeless person” and a “homeless child or youth” have the same meaning as
defined in 42 United States Code Section (
11301 et seq.
U.S.C.)
A “homeless services provider,” as defined by statute, who has knowledge of a
person’s status as homeless, must provide verification through completion of the
affidavit.
The affidavit will not be considered complete unless signed by both the homeless
services provider and the person making the request for the birth record.
A “homeless services provider” includes:
1) A governmental or nonprofit agency receiving federal, state, or county or municipal
funding to provide services to a “homeless person” or “homeless child or youth,” or
that is otherwise sanctioned to provide those services by a local homeless
continuum of care organization.
2) An attorney licensed to practice law in this state.
3) A local educational agency liaison for homeless children and youth designated as
such pursuant to Section 11432(g)(1)(J)(ii) of Title 42 of the United States Code, or
a school social worker.
4) A human services provider or public social services provider funded by the State of
California to provide homeless children or youth services, health services, mental or
behavioral health services, substance use disorder services, or public assistance or
employment services.
5) A law enforcement officer designated as a liaison to the homeless population by a
local police department or sheriff’s department within the state.
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