Vital Records Application Form printable pdf download

City of Yoakum Local Registrar

Vital Records Application Form

PO Box 738/808 Hwy 77A South

Revised July 2014

Yoakum, TX 77995

Phone #: (361) 293-6321 Fax #: (361) 293-3318

Instructions:

•

Read ALL instructions carefully before completing and submitting this application.

•

If any relevant part of this application is left blank, it will be returned to you.

•

Valid identification must be presented

to verify you are a qualified applicant

(a copy will be made)

•

A LONG FORM BIRTH CERTIFICATE is recommended if applying for a PASSPORT.

•

Birth records are confidential for 75 years from the date of birth; therefore, issuance is restricted to a qualified applicant

ONLY.

•

Death records are confidential for 25 years from the date of death; therefore, issuance is restricted to a qualified applicant

ONLY.

PLEASE PRINT

Applicant’s Information

(this is you)

Your Name:

Phone #:

Relationship To Individual on

Record:

Address (Mailing/Physical):

City:

State:

Zip:

Reason For Obtaining A Copy of This Record:

Your Signature:

Date:

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 this form which contains

a false statement can result in 2-10 years in prison and a fine of up to $10,000 (Health & Safety Code, Chapter 678, Sec.195.003)

Record

(information on certificate)

Name on Record:

Date of Birth/Death:

Sex:

☐ Male

☐ Female

City & County of Birth/Death:

For Death – Date of Birth:

For Death – Place of Birth:

Mother’s First Name:

Middle:

MAIDEN

Last

Father’s First Name:

Middle

Last

(IF listed)

What are you applying for

(please check box below)

☐

Birth Certificate

☐ Abstract/Short Form OR ☐ Long

)

Form

(born in YOAKUM - 1947 to present ONLY

$23.00 x #________copies = $________

We accept Check, Cash, Money Order, Visa or Mastercard - please add

3.2% additional cost for processing of a debit/credit card.

($23.74 if by credit/debit card)

Fee rates are set by the Texas Board of Health and are not mandated by the Texas

☐

Legislature. For any search where a record is not found, the search fee is NOT

Death Certificate

(died in Yoakum – 1948 to present ONLY)

refundable or transferrable.

$21.00 – 1

Copy

($21.67 if by credit/debit card)

$3.00 x #________ additional copies = $________

($3.10 if by credit/debit card)

(Death certificates obtained at a different date/time will accrue a new fee of $21.00)

If mailing & paying by credit/debit card:

MUST PRESENT VALID IDENTIFICATION & SUBMIT PAYMENT

Name on Card:_______________________

BEFORE APPLICATION IS PROCESSED.

Card #:_____________________________

Signature:__________________________

It is recommended that vital records be mailed to you via a traceable method

Expiration Date:_____________________

(certified mail, UPS, FedEx) - additional fees will apply, please call our office.

FOR OFFICE USE ONLY:

Identification Type:__________________________________Document #:________________________Expiration:____________

Other identification, if required:_______________________________________________________________________________

OBTAIN COPY OF ALL ID/DOCUMENTATION PROVIDED

Local Registrar/State File #:____________________  Birth Certificate Abstract/Short Form  Long Form

 Death Certificate

Type of Payment:  Cash  Check #_________  Money Order  Credit Card – Mastercard OR Visa

Vital Records Application Form

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