American LegalNet, Inc. www.FormsWorkFlow.com Dallas County Clerk Records Building 2nd floor 509 Main Street Dallas, Texas 75202 (214) 653-7099 Application for a certificate of Birth or Death Certificate Birth $23.00 Death Certificates $21.00 for first page and $4.00 for each additional copy of same record. Birth records are confidential for 75 years and Death records are confidential for 25 years. A valid government issued ID or driver’s license is required to obtain the records. Only properly qualified applicants can obtain this record, which include; Self Spouse Parent Grand Parent Child Sibling Legal Representative Warning: The penalty for knowingly making a false statement on this form can be 2-10 years in prison and a fine of up to $10,000 (Texas Health and Safety Code, Chapter 678, Sec. 195.003) INSTRUCTIONS FOR APPLICATION FOR CERTIFIED COPY OF A BIRTH OR DEATH RECORD Check the appropriate box for either a Texas Birth or Death record. Indicate the number of records requested and compute the amount of money to be sent. PLEASE DO NOT SEND CASH OR PERSONAL CHECKS THROUGH THE MAIL. PLEASE SEND A MONEY ORDER MADE PAYABLE TO: DALLAS COUNTY CLERK Item 1. Name of Record: State the FULL NAME of the person shown on the record being requested. Item 2. Date of Event: (The date of the birth OR death.) Give the exact date of the birth or day the person died. (If you do not know the exact date of death, then give the date the person was last known to be alive.) Item 3. Sex Enter Male or Female. Item 4. Place of Event: State the name of the city or county in which the birth or death occurred. (If you do not know the exact place of death, show the last address known when the person was alive.) Item 5. Father’s Name: Give the full name of the father of the person shown on the record. Item 6. Mother’s Maiden Name: Give the FULL MAIDEN NAME of the mother of the person shown on the record. Item 7. Applicant’s Name: Give YOUR full name Item 8. Telephone Number: Give us a telephone number with area code where you can be reached between the hours of 8:00 A.M. and 4:30 P.M. (Central Time) Monday through Friday. Item 9. Mailing Address: Give us a complete current mailing address. Item 10. Relationship to person named on the record. State how you are related to the person whose record you are requesting. Item 11. Purpose for obtaining this record: State the reason or purpose for which you are requesting this record. Item 12. ADDITIONAL IDENTIFYING INFORMATION FOR DEATH CERTIFICATE: This additional information assists our staff in positively identifying a record. Indicate the full name of the hospital where the certificate holder was born at. SIGN AND DATE THE APPLICATION. ENCLOSE A PHOTOCOPY OF YOUR ID WITH A PICTURE ON IT (PHOTOCOPY OF PICTURE ID). MAIL TO ADDRESS AT TOP OF APPLICATION FORM WITH THE CORRECT FEE(S). American LegalNet, Inc. www.FormsWorkFlow.com