Application Form For Certified Copy Of Birth Certificate (Page 2 of 2) in pdf

Application Form For Certified Copy Of Birth Certificate Page 2

NOTARIZED PROOF OF IDENTIFICATION

PART I. ENTER NAME, DATE AND PLACE OF BIRTH/DEATH, AND NAMES OF PARENTS AS INFORMATION APPEARS ON

BIRTH/DEATH CERTIFICATE

FULL NAME OF PERSON ON RECORD

DATE OF BIRTH/DEATH

PLACE OF BIRTH/DEATH (CITY OR COUNTY)

SEX

FULL NAME OF PARENT 1

FULL NAME OF PARENT 2

PART II. ENTER RELATIONSHIP TO PERSON ON RECORD AND THE TYPE OF ID USED.

NAME AND RELATIONSHIP TO PERSON ON RECORD

TYPE AND NUMBER OF ID ACCEPTED WHEN NOTARIZED

AFFIDAVIT OF PERSONAL KNOWLEDGE

PART III. THIS SECTION MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC.

STATE OF _________________

COUNTY OF _______________

Before me on this day appeared ________________________________________________________________________

(name)

now residing at _____________________________________________________________________________________

(Address)

(City)

(State)

who is related to the person named in Part I as __________________________________________ and who on oath deposes

(relationship)

and says that the contents of this affidavit are true and correct.

Signature ______________________________________

Sworn to and subscribed before me, this _____ day of ______________, 20 ____.

(Please place notary stamp in space below)

Signature of Notary Public

Matricula card is not an acceptable

Commission Expires

form of identification.

Typed or Printed Name

Street Address

City, State and Zip

WARNING: IT A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY MAKING A FALSE

STATEMENT ON THIS FORM OR FOR SIGNING A FORM WHICH CONTAINS A FALSE STATEMENT IS 2 TO 10 YEARS IMPRISONMENT

AND A FINE OF UP TO $10,000. (HEALTH AND SAFETY CODE, CHAPTER 195, SEC. 195.003)

MAIL THIS SWORN STATEMENT, APPLICATION, PAYMENT (MONEY ORDER OR CASHIER CHECK) AND A PHOTOCOPY OF YOUR VALID

PHOTO ID TO:

ECTOR COUNTY CLERK

VITAL RECORDS

PO BOX 707

ODESSA TX 79760

(APPLICATION WITHOUT THE SWORN STATEMENT AND PHOTO ID WILL NOT BE PROCESSED)

Page 2 of 2

Application Form For Certified Copy Of Birth Certificate Page 2

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