LARRY WALKER Auditor-Controller/Recorder Treasurer/Tax Collector County Clerk San Bernardino County APPLICATION FOR CERTIFIED COPY BIRTH Certificate ($19.00) DEATH Certificate ($12.00) MARRIAGE Certificate ($14.00) INFORMATION: San Bernardino County only has records of births and deaths that occurred in San Bernardino County or marriage licenses that were purchased in San Bernardino County. For all other vital records you must contact the county in which the event is registered 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 requested. All sections must be completed in their entirety. If no record of the event is found, the fee will be retained for searching as required by statute and a “Certification of Search” will be issued. 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 vital 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 with a legend stating “INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY.” This application must be completed prior to conducting a search for the record and no refunds or exchanges will be made once the copy(s) have been 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-of-country requests), made payable to the “San Bernardino County Recorder.” 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 INDICATE THE TYPE OF CERTIFICATE REQUESTED AND PRINT LEGIBLY OR TYPE ALL INFORMATION BELOW: Name on Certificate - First Name Middle Name Last Name on Certificate Second Person on Certificate (Marriage) - First Name Middle Name Last Name on Certificate City or Town of Event Maiden Name of Mother (Birth and Death only) Name of Father (Birth and Death only) (Birth Cert. Only) Male Sex: Female Date of Event Number of Copies Requested Certified Copy Informational Copy Please Indicate: 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 Informational Copies - I agree not to use the birth record obtained from this application or any portion thereof, for fraudulent purposes. Certified Copies - 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 Amendment Number(s) Date Processed Counter Mail Rev. 11/01/10 Type of ID and Identifying Numbers Bank Note Paper Number(s) Reg Inf. Copy CTF No Record LDC 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. Dated 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 before me, On (Date) , (Name and title of officer) , who proved to me on the basis of (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. personally appeared 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