Application For Birth Record And Notarized Certificate printable pdf download

COUNTY OF LOS ANGELES Ÿ REGISTRAR-RECORDER/COUNTY CLERK, P.O. BOX 489, NORWALK, CA 90651-0489 (562) 462-2137

APPLICATION FOR BIRTH RECORD

Pursuant to Health and Safety Code 103526, the following individuals are entitled to an AUTHORIZED certified copy of a birth

record:

◈ The registrant or a parent or legal guardian of the registrant

◈ A party entitled to receive the record as a result of a court order, or an attorney or a licensed adoption agency seeking

the birth record in order to comply with the requirements of Section 3140 or 7603 of the Family Code

◈ A member of a law enforcement agency or a representative of another governmental agency, as provided by law, who

is conducting official business

◈ A child, grandparent, grandchild, sibling, spouse or domestic partner of the registrant

◈ An attorney representing the registrant or the registrant's estate, or any person or agency empowered by statute or

appointed by a court to act on behalf of the registrant or the registrant's estate

MAIL REQUESTS FOR AUTHORIZED COPIES MUST BE ACCOMPANIED BY A NOTARIZED CERTIFICATE OF IDENTITY.

"INFORMATIONAL, NOT A

Those who are not authorized may receive an INFORMATIONAL certified copy with the words

VALID DOCUMENT TO ESTABLISH IDENTITY" imprinted across the face of the copy.

WE CAN ONLY PROVIDE COPIES FOR BIRTHS THAT OCCURRED IN LOS ANGELES COUNTY.

c I am requesting an AUTHORIZED copy

CERTIFICATE TYPE:

c I am requesting an INFORMATIONAL copy

Note: c Check box if ADOPTED. Enter adopted name and parents’ information on application.

Please PRINT all information legibly.

NUMBER OF COPIES

FOR RECORDER USE ONLY

Por favor imprima legible toda la informacion.

NUMERO DE COPIAS

Month/Mes

Day/Dia

Year/Año

Date of Birth – Fecha De Nacimiento

File Number

NAME GIVEN AT BIRTH (first, middle, last) – NOMBRE DE NACIMIENTO (primero, segundo, apellido)

Searched

CITY OF BIRTH – CIUDAD DE NACIMENTO

Doubled

BIRTH NAME OF FATHER/PARENT – NOMBRE DE NACIMIENTO DEL PADRE/PADRE

BIRTH NAME OF MOTHER/PARENT – NOMBRE DEL NACIMIENTO DE MADRE/MADRE

RELATIONSHIP TO REGISTRANT (SEE ABOVE) - PARENTESCO CON LA PERSONA REGISTRADA (VEÁSE ARRIBA)

I ____________________________________ certify (or declare) under penalty of perjury under the laws

of the State of California that the foregoing is true and correct.

Date ___________________________

Signature__________________________________________________

DL/ID________________________

Phone Number __________________________

Complete your name and mailing address below. Print legibly.

Escriba abajo su nombre y direccion. Imprima legible.

NAME/NOMBRE

STREET ADDRESS/NUMERO Y CALLE

CITY/CIUDAD

STATE/ESTADO

ZIP/ZONA POSTAL

76A639B Rev. 6/16

Application For Birth Record And Notarized Certificate

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