Application Form For Certified Copy Of Birth Certificate

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APPLICATION FOR CERTIFIED COPY OF BIRTH CERTIFICATE
Ector County Clerk
Office Use Only
Linda Haney
Each Certified Copy……………. $23.00
PO Box 707
Number Requested……………
Odessa TX 79760
Total Due………………………. $
432-498-4130
Certificate NO. ……………...…
Cash
Check#
Debit/credit
I wish to make a $5 donation for the Texas
Home Visiting Program for healthy early childhood
(Only money orders/cashier checks by mail)
WARNING: The penalty for knowingly making a false statement on this form can be 2-10 years in prison and a fine
of up to $10,000.00(Health & Safety Code 195.003)
Please Print:
Information Found on Birth Certificate
1.
Full Name on Record: (first, middle, last)
2.
Date of Birth:
3.
Place of Birth: (City, County)
4.
Parent 1 Full Name:
Maiden/Birth Last Name
5.
Parent 2 Full Name:
Maiden/Birth Last Name
Information about Applicant
6.
Applicant’s Full Name:
7.
Applicant’s Mailing Address:
City, State, Zip Code
8.
Telephone Number:
9. Email Address
10.
Applicant’s Relationship to Person Named in #1:
11.
Purpose for Obtaining Record:
Signature of Applicant
Today’s Date
(COPY OF APPLICANT’S PHOTO ID IS REQUIRED)
For applications that are sent by mail:
The attached Notarized Proof of Identification/Affidavit of Personal Knowledge and copy of valid photo ID must be
attached to this completed application or the request will not be processed.
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