Form Ccr Vital 01 - Application For Certified Copy Of Birth Record

INSTRUCTIONS:

As of July 1, 2003, ONLY individuals who are authorized by Health and Safety Code Section 103526

can obtain a Certified Copy of a Birth Record to establish identity of the registrant. (Page 1 of the

application identifies the individuals who are authorized to make the request.) All others may receive a

Certified Informational Copy which will be marked, “Informational, Not a Valid Document to Establish

Identity.”

Complete a separate application form for each record of birth requested.

Complete the Applicant Information section on the first page of this form and provide your signature

where indicated. Provide all the information you have available to identify the record of the registrant

under Birth Certificate Information. If the information you furnish is incomplete or inaccurate, it may

be impossible to locate the record. If the registrant has been adopted, please make the request in

the adopted name.

SWORN STATEMENT:

•

The authorized individual requesting the certified copy must sign the attached Sworn Statement,

declaring, under penalty of perjury, that they are eligible to receive the certified copy of the birth

record and identify their relationship to the registrant.

•

If the application is being submitted by mail, your signature on the Sworn Statement must be

acknowledged by a Notary Public. (To locate a Notary Public, see your local yellow pages or

call your banking institution.).

•

Any member of a law enforcement agency or a representative of a state or local government agency, as

provided by law, who orders a copy of a record to which subdivision (a) applies in conducting official

business is required to complete the Sworn Statement, however, they may not be required to have their

signature on the Sworn Statement acknowledged by a Notary Public.

•

If the application is being submitted in person at the County Clerk and Recorders Office, the

Sworn Statement must be signed by you in the presence of the County Clerk and Recorder

staff, and your signature does not have to be acknowledged by a Notary Public. A Sworn

Statement does not need to be provided if you are requesting a Certified Informational Copy of

the birth record.

5. Submit $20 for each certified copy requested. If no record of the birth is found, the $20 fee will be

retained for searching the record (as required by law) and a Certificate of No Record will be issued to the

applicant. Indicate the number of certified copies you wish and include the correct fee(s) in the form of a

personal check, postal or bank money order (International Money Order for out-of-country requests)

made payable to the Ventura County Clerk and Recorder. Mail this application with the fee(s) and a

self-addressed stamped envelope to:

MARK A. LUNN

Ventura County Clerk and Recorder

800 S. Victoria Ave

Ventura, CA 93009-1260

Website:

Telephone number (805) 654-2295 Fax (805) 662-6543

Additional costs apply for

Credit card orders may be processed on-line at

processing orders using a credit card. Please follow the directions on Vitalcheks website if ordering

using a credit card.

BIRTH

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CCR Vital 01 (Rev01/2013)

Form Ccr Vital 01 - Application For Certified Copy Of Birth Record - 2013 Page 3

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