Sworn Statement Form - California Department Of Public Health

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State of California – Health and Human Services Agency

California Department of Public Health

SWORN STATEMENT

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, death, or marriage certificate of the following individual(s):

Applicant’s Relationship to Person Listed on Certificate

Name of Person Listed on Certificate

(Must Be a Relationship Listed on Page 1 of Application)

(The remaining information must be completed in the presence of a Notary Public or CDPH Vital Records staff.)

Subscribed to this ______ day of ______________, 20___, at ________________________________, _____________.

(Day)

(Month)

(City)

(State)

______________________________________________________

(Applicant’s Signature)

Note: If submitting your order by mail, you must have your Sworn Statement notarized using the Certificate of Acknowledgment

below. The Certificate of Acknowledgment must be completed by a Notary Public. (Law enforcement and local and state

governmental agencies are exempt from the notary requirement.)

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

CERTIFICATE OF ACKNOWLEDGMENT

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.

State of _______________________)

County of ______________________)

On ____________before me, _________________________________, personally appeared _______________________________________,

(insert name and title of the officer)

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