Application For Certified Copy Of Birth Certificate
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1BIRTH CERTIFICATE
APPLICATION FOR CERTIFIED COPY OF
APLICACION PARA CERTIFICADO DE NACIMIENTO
$23.00 EACH
COPIES NEEDED:______
OFFICE OF MARK STAPLES, ANDERSON COUNTY CLERK
For a PASSPORT you will need a LONG FORM BIRTH CERTIFICATE
_____ Standard (8.5” X 6.5”)
_____ Long (8.5” X 11”)
ANDERSON COUNTY ONLY
NAME ON RECORD
FIRST NAME/NOMBRE PRIMARIO
MIDDLE NAME/NOMBRE SEGUNDO
LAST NAME/APELLIDO
DATE OF BIRTH
COUNTY OF BIRTH
STATE
FECHA DE NACIMIENTO
CONDADO DE NACIMIENTO
ESTADO
TEXAS
DAY/DIA
YEAR/AŇO
MONTH/MES
MOTHER’S FULL MAIDEN NAME
FATHER’S FULL NAME
NOMBRE COMPLETO DE SOLTERA DE MADRE
NOMBRE COMPLETO DE PADRE
NAME OF PERSON MAKING THIS APPLICATION
PHONE:
NOMBRE DE APLICANTE
NUM. DE TELEFONO
RELATIONSHIP TO PERSON
ON BIRTH CERTIFICATE
REASON FOR THIS CERTIFICATE (CHECK ONE)
AFINIDAD
RASON POR LA APPLICACION (MARQUE UNO)
_____School _____ Sports _____ Drivers License _____I.D.
_____ Passport _____Travel _____ Insurance _____ Personal
_____ Social Security _____ Retirement ______ CPS
WARNING
: IT IS 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 2-10
YEARS IMPRISONMENT AND A FINE UP TO $10,000 (HEALTH AND SAFETY CODE, CHAPTER 195, SEC.195.003)
AVISO
: ES UN DELITO DE FALSIFICAR INFORMACION EN ESTE DOCUMENTO. PENALIDAD POR HACER UNA DECLARACION
FALSA EN ESTA APPLICACION PUEDE REULTAR EN 2-10 AŇOS EN LA CARCEL Y UNA MULTA DE HASTA $10,000 (CODIGO DE
SALUD Y SEGURIDAD CAPITULO 195, SEC.195.003)
X
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SIGNATURE OF APPLICANT/FIRMA
DATE/FECHA
THIS SPACE FOR OFFICE USE ONLY
CLERK’S:
IDENTIFICATION USED
CLERK’S:
IDENTIFICATION USED
FOR VER IFICATION_________________________________________
INITIALS_____________
FOR VER IFICATION_________________________________________
INITIALS_____________
CERTIFICATE NO:_________________________________ DATE ISSUED :____________________
CERTIFICATE NO:_________________________________ DATE ISSUED :____________________
Cash _____
Money Order _____
Cashier’s Check _____
Check _____
Credit Card_____
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