- - - - - - - - - - --- American LegalNet, Inc. www.FormsWorkFlow.com .............................................. . . . . . . . . . . . . . . .............................................. - - - - - - - - - - - - --- - - - American LegalNet, Inc. www.FormsWorkFlow.com D D D D D D D D D D D D I I D D D D D D D D State of California 226 Health and Human Services Agency California Department of Public Health APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD PLEASE READ THE INSTRUCTIONS ON PAGE 2 BEFORE COMPLETING THIS APPLICATION California law (Health and Safety Code Section 103526), permits only authorized individuals as listed on the application to receive certified copies of birth records. Those who are not authorized by law to receive an authorized certified copy will receive a certified informational copy with the legend, 223INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY.224 Please indicate the type of certified copy you are requesting: I am requesting a Certified AUTHORIZED copy I am requesting a Certified INFORMATIONAL copy NOTE: Both documents are certified copies of the original document on file with the California Department of Public Health 226 Vital Records (CDPH-VR). With the exception of the legend and redaction of signatures and Social Security Number, the documents contain the same information. To receive an AUTHORIZED copy, you MUST INDICATE YOUR RELATIONSHIP TO THE REGISTRANT below. To receive a certified copy, the applicant must sign a sworn statement that he or she is authorized to receive the certified copy. The Sworn Statement MUST BE NOTARIZED unless you are a member of a law enforcement agency or a representative of a state or local government agency. RELATIONSHIP: Registrant (Name on Certificate) Child/Sibling of Registrant Grandparent/Grandchild of Registrant Spouse/Registered Domestic Partner of Registrant Authorized by Court Order (Include copy of the court order.) Attorney Representing Registrant or Registrant222sEstate Law Enforcement/Govt. Agency (Conducting Official Business) Attorney/Licensed Adoption Agency (Under CA Family Code 247 3140 or7603) Parent/Legal Guardian of Registrant (Legal guardian must provide documentation.) Power of Attorney/Executor of the Registrant222s Estate (Include a copy of the power of attorney or supporting documentation identifying you as executor.) APPLICANT INFORMATION (PRINT OR TYPE) Today222s Date: Agency Name (If Applicable) Agency Case Number Inmate ID Number Name of Person Completing Application Signature of Applicant Purpose of Request Check this box for CNPR Request Mailing Address 226 Number, Street, and Unit # (if applicable) Amount Enclosed 226 DO NOT SEND CASH $ Check $ Money Order Number of Copies City Name of Person Receiving Copies if Different from Applicant State/Province ZIP Code Country Mailing Address for Copies if Different from Applicant Daytime Telephone Number ( ) Email Address City State ZIP Code BIRTH RECORD INFORMATION (PRINT OR TYPE) Adopted: No Yes (If Yes, see #4 on Page 2) Complete the information below as shown on the birth record, to the best of your knowledge. FIRST Name MIDDLE Name LAST Name City of Birth (must be in California) County of Birth Date of Birth 226 MM/DD/YYYY (If unknown, enter approximate date) FIRST Name Mother Father Parent MIDDLE LAST (Birth/Before Marriage/Domestic Partnership) FIRST Name Mother Father Parent MIDDLE LAST (Birth/Before Marriage/Domestic Partnership) FEE: $25 PER COPY (PAYABLE TO CDPH VITAL RECORDS) Submit Check or Money Order 226 Do Not Send Cash Check/Money Order Enclosed Notarized Sworn Statement Enclosed (if applicable) You may view current processing times at www.cdph.ca.gov BIRTH VS 111 (01/18) Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com INFORMATION: Birth records have been maintained by the California Department of Public Health 226 Vital Records (CDPH-VR) since July 1, 1905. The name required on Vital Records (see Items 1C, 6C, 7C, 9C, and 12C) is the name given at birth, or a name received through adoption, court-ordered name change, or naturalization. AKAs (Also Known As) and assumed names cannot be entered as the legal name on the birthrecord. INSTRUCTIONS: 1. 2. 3. 4. 5. 6. SWORN STATEMENT: 7. 8. ONLY individuals who are authorized by Health and Safety Code Section 103526 can obtain a Certified Copy of a birth record to establish identity of the registrant (person listed on the certificate). Page 1 identifies the individuals who are authorized to make the request. All others may receive a Certified Informational Copy which will be marked, 223Informational, Not a Valid Document to Establish Identity.224 Confidential Information on Birth Record: some individuals have special needs for a birth certificate that contains the confidential information provided at the time the birth record was prepared. This confidential information may be used to establish ethnicity, to provide health background, or for other personal reasons. For information on how to obtain a birth certificate containing the confidential information, please refer to the Birth Record section of the CDPH-VR website at: www.cdph.ca.gov. Only specific individuals may obtain confidential copies. Complete a separate application for each different birth record requested. Complete the Applicant Information section on Page 1 and provide your signature where indicated. In the Birth Record Information section, provide all the information you have available to identify the birth record. If the information you furnish is incomplete or inaccurate, CDPH-VR may not be able to locate the record. If the registrant has been adopted, make the request in the adopted name. If you are requesting a copy of the original birth certificate, you must provide a court order releasing the original sealed record. If you require documentation that a birth record does not exist, check the box for CNPR (Certificate of No Public Record) Request on the application. The authorized individual requesting the certified copy must sign the attached Sworn Statement, declaring under penalty of perjury that they are eligible to receive the certified copy of the birth record and identify their relationship to the registrant 226 the relationship must be one that is identified on Page 1. Only one sworn statement is required for multiplerecords. If the application is being submitted by mail, the Sworn Statement must be notarized by a Notary Public. To find a Notary Public, see your local yellow pages or call your banking institution. Law enforcement and local and state governmental agencies are exempt from the notary requirement. A Sworn Statement notarized by a foreign notary must have an apostille attached. An Apostille is a certificate that authenticates a document for use in another country. Foreign notarizations obtained from an Ambassador, Minister, Consul, Vice Consul or Consular Agent of the United States, or from a Judge of Court of record having a seal in a foreign country do not require an apostille. You do not have to provide a Sworn Statement if you are requesting a Certified Informational Copy of the birth record. Submit $25 for each copy requested. If no birth record is found, the fee will be retained for searching for the record (as required by law) and a 223Certificate of No Public Record224 will be issued to the applicant. Indicate the number of copies you want and include the correct fee(s) in the form of a personal check or postal or bank money order (International Money Order for out-of-country requests) made payable to CDPH Vital Records. PLEASE SUBMIT CHECK OR MONEY ORDER 226 DO NOT SEND CASH (CDPH cannot be held responsible for fees paid in cash that are lost, misdirected, or undelivered). Mail completed applications with the fee(s) to: California Department of Public Health Vital Records 226 MS 5103 P.O. Box 997410 Sacramento, CA 95899-7410 (916) 445-2684 BIRTH Page 2 of 3 VS 111 (01/18) American LegalNet, Inc. www.FormsWorkFlow.com ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- State