3. SWORN STATEMENT* (Must be signed in the presence of the Pasadena Vital Records Staff or a Notary Public.)
I, _________________________________________, declare under penalty of perjury under the laws of the State of California,
(Applicant’s Printed Name)
that I am an authorized person, as defined in California Health and Safety Code Section 103526 (c), and am eligible to receive a
certified copy of the birth certificate identified on this application form.
Subscribed to this__________ day of ____________________, 20______, at ______________________________, ________.
(Day)
(Month)
(City)
(State)
___________________________________
(Applicant’s Signature)
*If you are requesting a certified copy by mail, you must have the above statement and the certificate of acknowledgement
notarized. Please note: The notary is not certifying the relationship, only that you are the person requesting the copy.
Requests for an informational copy do not require your signature to be notarized.
SUBMITTING APPLICATION
By Mail:
Payment may be made by check or money order made payable to the City of Pasadena Public Health Department.
Do not mail cash.
Please provide a self-addressed stamped envelope.
The document(s) will be mailed to you within seven (7) business days.
In Person:
You will be asked to present valid photo identification.
Payment may be made with a credit card (American Express, Discover, MasterCard, Visa, Debit) cash or by
check/money order made payable to the City of Pasadena Public Health Department.
Please send or bring your completed application with the appropriate fee(s) to:
City of Pasadena Public Health Department
Vital Records Office
1845 North Fair Oaks Avenue, Room 1610
Pasadena, CA 91103
(626) 744-6010
OFFICE USE ONLY:
ID/DL#:__________________Exp:__________ LRN#:__________BN#:___________________________City Official: ______
⃝ Mail out
⃝ Hold for Pick-Up
⃝ Express/Same day service (additional fee required)
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Revised 6/2017