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Application For Birth Certificate (By Mail) Form. This is a California form and can be use in San Diego Local County.
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Tags: Application For Birth Certificate (By Mail), V01M, California Local County, San Diego
COUNTY OF SAN DIEGO ERNEST J. DRONENBURG, JR. ASSESSOR/RECORDER/COUNTY CLERK www.sdarcc.com BY MAIL APPLICATION FOR A BIRTH CERTIFICATE, OR LETTER OF NO RECORD FOR OFFICIAL USE ONLY $28.00 PER COPY FEES NON-REFUNDABLE Per California State Law, Health and Safety Code, Section 103526(c), permits only authorized persons as defined below to receive certified copies of Birth Records. Those who are not authorized by Law to request a certified copy will receive a certified informational copy marked "INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY." Type of identification provided, if processed in person: FOR OFFICIAL USE ONLY Driver's License Passport Military ID Other ____________ If we cannot identify the record based on the information you provided, State Law requires that we retain the fee and issue a "Letter of No Record". Please wait 3 weeks from the date of the event before submitting your request. You will be asked to present a valid photo ID for all in-person requests. I would like a Certified Copy of the record identified on the application I would like a certified Informational Copy of the record identified form. (In order to receive a Certified Copy, you must indicate your on the application form. (You are not required to select from the relationship to the person named on the application form by selecting list below or complete the statement of identity in order to receive from the list below.) an Informational Copy.) I am: The registrant (person named on certificate) 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 requirement 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. BIRTH INFORMATION ON CERTIFICATE (PLEASE PRINT OR TYPE) - $28.00 for each certified copy First Name Middle Name Last Name Date of Birth Full Birth Name (First Middle Last) of Birth Mother/Parent Giving Birth County of Birth No. of Copies BIRTH INFORMATION ON CERTIFICATE (PLEASE PRINT OR TYPE) - $28.00 for each certified copy First Name Middle Name Last Name Date of Birth Full Birth Name (First Middle Last) of Birth Mother/Parent Giving Birth County of Birth No. of Copies BIRTH INFORMATION ON CERTIFICATE (PLEASE PRINT OR TYPE) - $28.00 for each certified copy First Name Middle Name Last Name Date of Birth Full Birth Name (First Middle Last) of Birth Mother/Parent Giving Birth County of Birth No. of Copies Note: The Statement of Identity must accompany this request in our office before a certificate can be issued. Requestor's Name _______________________________________________________________________ PLEASE PRINT V01M (02/10/17) American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 2 SWORN STATEMENT I, ______________________________________________, declare under penalty of perjury under the laws of the State of California, that I am an authorized person, as defined in California Health and Safety Code, Section 103526 (c), and am eligible to receive a certified copy of the birth record of the following individual(s): (Print Name) Name of Person Listed on Certificate Number of Copies Applicant's Relationship to Person Listed on Certificate Subscribed to this _______ day of ______________, 20_____, at ________________________________, ________________. (Day) (Month) (Yr) (City) (State) ______________________________________________________ (Applicant's Signature) Note: If submitting your order by mail and requesting a Certified Copy, you must have your sworn statement notarized using the Certificate of Acknowledgment below. The notary is only verifying the identity of the person requesting the copy not the relationship to the registrant. Only one notarization is required even though the requestor may have a different authorized relationship to each being requested, (i.e. Mother on one request, Registrant on another request, etc.). A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not to the truthfulness, accuracy, or validity of that document. CERTIFICATE OF ACKNOWLEDGMENT State of _______________________________ County of _____________________________________________________ On _______________________________ before me, ________________________________________________________, Personally appeared _____________________________________ who proved to me on the basis of 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 Personally Known OR Produced Identification. Type of Identification produced _________________________ (Here insert name and title of officer) ________________________________________________ NOTARY SIGNATURE Mail Certificate to: Name __________________________________________________ Address ________________________________________________ City, State, Zip ___________________________________________ Email __________________________________________________ Phone (______) _________________________________________ Number of copies ____________X $28.00 = ___________________ V01M (02/10/2017) Please mail this request along with your payment (check or money order payable to San Diego County Recorder) to: San Diego Recorder/County Clerk Attn: Vital Records P.O. Box 121750 San Diego, CA 92112-1750 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2