For multiple mail requests only ONE Sworn Statement & Certificate of Acknowledgment is Required Per Applicant
SWORN STATEMENT
I, , declare under penalty of perjury under the laws of the State of California, that I am
(Applicant’s Printed Name)
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):
Name of Person Listed on Certificate
# of Copies
Applicant’s Relationship to Person Listed on Certificate
(Must be a relationship listed on page 1 of the application)
Subscribed to this day of _, 20 , at , _.
(Day) (Month) (Year) (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.).
CERTIFICATE OF ACKNOWLEDGMENT
State of County of
On before me, ,
(Date) (Insert name and title of the officer)
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.
SIGNATURE OF NOTARY PUBLIC
Mail Birth Certificate to:
Name _________________________________________
Address ________________________________________
City, State, Zip __________________________________
Email __________________________________________
Phone ( _______ ) _______________________________
# of Copies _______________ X $32.00 =
___________
P
lease 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
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.
