Laura Richard Fort Bend County Clerk Phone: (281) 341-8685 Fax: (281) 341-8669 Email: cclerk@fortbendcountytx.gov APPLICATION FOR BIRTH OR DEATH CERTIFICATE *BIRTH CERTIFICATE *DEATH CERTIFICATE Certified Copies Requested PLEASE PRINT Certified Copies Requested @ $23.00 each = $ $21.00 First Copy Please check this box to make a voluntary contribution $ 4.00 Additional Copies of the Same of $5 to promote healthy early childhood. (HSC 191.0048) Record/Request *Search Fee is non-refundable for Birth & Death Records (TAC 25 Chapter 181) (NO PERSONAL CHECKS ACCEPTED) 1. Full Name of Person on Record First Name Middle Name Last Name 2. Date of Birth or Date of Death Month Day Year 3. Sex 4. Place of Birth or Place of Death City or Town County State TEXAS 5. Full Name of Parent First Name Middle Name Last Name (Maiden, if applicable) 6. Full Name of Parent First Name Middle Name Last Name (Maiden, if applicable) 7. APPLICANT222S NAME: 8. RELATIONSHIP TO PERSON NAMED IN ITEM 1 (Give YOUR full name) 9. MAILING ADDRESS: STREET ADDRESS CITY STATE ZIP 10. TELEPHONE NUMBER AND EMAIL ADDRESS: () EMAIL ADDRESS 11. PURPOSE FOR OBTAINING THIS RECORD: 12. ADDITIONAL IDENTIFYING INFORMATION FOR DEATH CERTIFICATE: SOCIAL SECURITY # OF DECEASED BIRTH DATE BIRTH PLACE WARNING: THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT IN THIS FORM CAN BE 2-10 YEARS IN PRISON AND A FINE OF UP TO $10,000. (HEALTH AND SAFETY CODE, CHAPTER 195, SEC. 195.003) YOUR SIGNATURE DATE OF APPLICATION 273273IF REQUESTING BY MAIL, PLEASE INCLUDE A VALID, LEGIBLE COPY OF PHOTO DL / ID CARD OF THE APPLICANT AND THE ATTACHED SWORN (NOTARIZED) STATEMENT253253 OFFICE USE ONLY CERT #(S) AMOUNT $ DATE CASH CREDIT OTHER RECEIPT # DOCUMENT CONTROL # BY EXP IDENTIFICATION TYPE (DL, ID CARD, ETC.) NUMBER (ON DL, ID CARD, ETC.) DOB ***To process in person you may visit one of the following locations*** 301 Jackson, Suite 101 307 Texas Pkwy 22333 Grand Corner Drive 5855 Sienna Springs Way Richmond, Texas 77469 Missouri City, Texas 77489 Katy, Texas 77494 Missouri City, Texas 77459 (Mailing address) American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR APPLICATION FOR CERTIFIED COPY OF A BIRTH OR DEATH CERTIFICATE Indicate the number of records requested and compute the amount of money to be sent. PLEASE DO NOT SEND CASH THROUGH THE MAIL. WE SUGGEST YOU SEND A MONEY ORDER MADE PAYABLE TO: FORT BEND COUNTY CLERK. NO CHECKS PLEASE. THE SWORN STATEMENT MUST ALSO BE INCLUDED FOR MAIL-IN REQUESTS. Item 1. Name on 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. Parent222s Name: Give the full name of the parent of the person shown on the record. Give the FULL MAIDEN NAME of the mother, if applicable. Item 6. Parent222s Name: Give the full name of the parent of the person shown on the record. Give the FULL MAIDEN NAME of the mother, if applicable. Item 7. Applicant222s Name: Give YOUR full name Item 8. Relationship to person named on the record: State how you are related to the person whose record you are requesting. Item 9. Mailing Address: Give us your complete current mailing address. Item 10. Telephone Number and Email Address: Give us the telephone number with area code where you can be reached between the hours of 8 a.m. and 5 p.m., Monday through Friday along with your email address. 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 when exact dates, places and spelling of the name(s) are not known for a death certificate: Social Security Number of the deceased Birthdate of the deceased Birthplace of the deceased Any other information that would be helpful in identifying the record of an individual. NOTE: FEES ARE SUBJECT TO CHANGE WITHOUT NOTICE (CALL 281.341.8685 FOR FEE VERIFICATION). THE SEARCHING FEE IS NON-REFUNDABLE EVEN IF A RECORD IS NOT FOUND. BIRTH RECORDS ARE CONFIDENTIAL FOR 75 YEARS AND DEATH RECORDS ARE CONFIDENTIAL FOR 25 YEARS; THEREFORE ISSUANCE IS RESTRICTED. OTHER RECORDS MAY BE OBTAINED WHEN SUFFICIENT INFORMATION FOR IDENTIFICATION IS PROVIDED. A VALID PHOTO ID IS REQUIRED PRIOR TO RECEIVING SERVICE. A PHOTOCOPY OF A VALID PHOTO ID MUST ACCOMPANY THE APPLICATION WHEN RETURNING BY MAIL OR FAX. FAILURE TO PROVIDE REQUIRED INFORMATION MAY CAUSE YOUR REQUEST TO BE REJECTED. American LegalNet, Inc. www.FormsWorkFlow.com NOTARIZEDPROOFOFIDENTIFICATIONPARTI.ENTERNAME,DATEANDPLACEOFBIRTH/DEATH,ANDNAMESOFPARENTSASINFORMATIONAPPEARSONBIRTH/DEATHCERTIFICATE FULLNAMEOFPERSONONRECORDDATEOFBIRTH/DEATH PLACEOFBIRTH/DEATH(CityorCounty)SEX FULLNAMEOFPARENT1FULLNAMEOFPARENT2 PARTII.ENTERRELATIONSHIPTOPERSONONRECORDANDTHETYPEOFIDUSED. NAMEANDRELATIONSHIPTOPERSONONRECORDTYPEANDNUMBEROFIDACCEPTEDWHENNOTARIZED AFFIDAVITOFPERSONALKNOWLEDGE PARTIII.THISSECTIONMUSTBESIGNEDINTHEPRESENCEOFANOTARYPUBLIC. STATEOFCOUNTYOFBeforemeonthisdayappeared(Name)nowresidingat(Address)(City)(State)(ZipCode)whoisrelatedtothepersonnamedonPartIasandwhoonoathdeposesand(Relationship)saysthatthecontentsofthisaffidavitaretrueandcorrect.SignatureofAffiantSworntoandsubscribedbeforeme,thisdayof20. (Seal)SignatureofNotaryPublic CommissionExpires TypeorPrintedName NotaryIdentification WARNING:ITISAFELONYTOFALSIFYINFORMATIONONTHISDOCUMENT.THEPENALTYFORKNOWINGLYMAKINGAFALSESTATEMENTONTHISFORMORFORSIGNINGAFORMWHICHCONTAINSAFALSESTATEMENTIS2TO10YEARSIMPRISONMENTANDAFINEUPTO$10,000.(HEALTHANDSAFETYCODE,CHAPTER195,SEC.195.003)MAILTHISSWORNSTATEMENT,APPLICATION,PAYMENTANDAPHOTOCOPYOFYOURVALIDPHOTOIDTO:FORTBENDCOUNTYCLERK301JACKSONSTREETRICHMOND,TEXAS77469(APPLICATIONSWITHOUTTHESWORNSTATEMENTANDPHOTOIDWILLNOTBEPROCESSED) American LegalNet, Inc. www.FormsWorkFlow.com