Application for a San Bernardino County Birth Certificate LARRY WALKER Auditor/Controller-Recorder County Clerk INFORMATION: San Bernardino County only has records of births that occurred in San Bernardino County. For all other birth records you must contact the county in which the birth occurred or contact the State Office of Vital Records – M.S. 5103, P.O. Box 997410, Sacramento, CA 95899-7410. Phone Number: (916) 445-2684. INSTRUCTIONS: Use a separate blank application for each record of birth requested. All sections must be completed in their entirety. The fee is $17.00 for each certified copy requested. If no record of the birth is found, the $17.00 fee will be retained for searching as required by statute and a “Certification of No Record” will be issued. PAYMENT OPTIONS: Mail orders – Check or credit card (Visa or Mastercard only). All mail orders are subject to a $4.00 processing fee. Include with this application sufficient money, in the form of a personal check, postal or bank money order (International Money Order only for out-ofcountry requests), made payable to the “San Bernardino County Recorder”. The fee is $17.00 for each certified copy. Mail this application along with the fee to the San Bernardino County Recorder’s Office, 222 West Hospitality Lane, San Bernardino, CA 92415. Please allow 3-5 weeks processing time. Walk-in customers - Check or cash for same day service. Doors are open 8 a.m. to 4:00 p.m., Monday – Friday, excluding holidays. CERTIFICATE INFORMATION – PLEASE PRINT LEGIBLY OR TYPE 1. Give all the information you have available for the identification of the record. If the information you furnish is incomplete or inaccurate, it may be impossible to locate the record. 2. The County Recorder may provide a certified copy of a birth record to an authorized person only. If a requestor does not meet the requirement of an authorized person (as described in Health & Safety Code Section 103526), the County Recorder may only issue an informational certified copy of birth with a legend stating “INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY.” This section of the application must be completed prior to submission and no refund or exchanges will be made after the copy has been issued. Please indicate the number of certified copies you are requesting. Name on Certificate – First Name Middle Name Last Name on Certificate City or Town of Birth Date of Birth Number of Copies Requested Indicate “Certified” Copy or “Informational” Copy: Maiden Name of Mother Sex: Male ‫ڤ‬ Female ‫ڤ‬ Name of Father APPLICANT INFORMATION – PLEASE PRINT LEGIBLY OR TYPE 1. When Appearing In Person – COMPLETE BOTH TOP AND BOTTOM PORTIONS. San Bernardino County requires photo identification. You will need to sign the application under penalty of perjury in front of a member of our staff. 2. Mail Requests – Complete both top and bottom portions. but do not sign the Penalty of Perjury statement. See the reverse side. Purpose for Which Certificate is to Be Used Relationship to Certificate Holder Name of Person Completing Application Daytime Telephone Number – Area Code First Address – Number, Street, and Unit # (if applicable) City State Zip Code  I agree not to use the birth record obtained from this application or any portion thereof, for fraudulent purposes.  I agree not to use the birth record obtained from this application or any portion thereof, for fraudulent purposes. I am signing my own legal name and I am an authorized person as shown in Health and Safety Code Section 103526. 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 BELOW SECTION FOR RECORDER’S USE ONLY Local Registration Number Date Processed Rev. 06/18/09 Amendment Number(s) (Circle One) Counter Mail Bank Note Paper Number(s) Type of I.D. and Identifying Numbers Reg ‫ڤ‬ Info. Cpy CTF. No Record ‫ڤ‬ ‫ڤ‬ Clerk’s Initials American LegalNet, Inc. www.FormsWorkFlow.com Mail Requests – Payment may be made by check, postal or bank money order, cashier’s check, Visa or Mastercard. Please check the appropriate box: Check Enclosed Money Order/Cashier’s Check Credit Card # V-Code (V-Code is the last 3 digits on the signature line located on the back of the card) Type of Card Expiration Date (Visa or Mastercard) (Subject to a processing fee) IMPORTANT Unauthorized Persons/Informational Copies – Please sign below. I agree not to use the record obtained from this application or any portion thereof, for fraudulent purposes. Signature Authorized Persons/Regular Certified Copies – Requestor will need to sign this penalty of perjury statement in front of a notary public prior to submission. Please Note: When submitting multiple certificate requests, all must be signed, however, only one request would require the notarized statement. I agree not to use the record obtained from this application or any portion thereof, for fraudulent purposes. I am signing my own legal name and I am an authorized person as shown in Health and Safety Code Section 103526. I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Signature CERTIFICATE OF ACKNOWLEDGMENT STATE OF _________________________________ COUNTY OF _______________________________ On ___________________________________ (Date) before me, _________________________________________________________, (Name and title of the officer) , who proved to me on the basis of personally appeared _______________________________________________________ _ (Name of person signing) satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. _____________________________________________________________ Signature of officer (Seal) American LegalNet, Inc. www.FormsWorkFlow.com