DH 1958, 08/2010, Florida Administrative Code Rule 64V-1.0131 (Obsoletes Previous Editions)
AFFIDAVIT TO RELEASE BIRTH CERTIFICATE
ATTENTION: This form must be completed in the presence of a Notary Public
(If you are eligible to receive the birth certificate requested below, you may use this form to name another person to
receive the birth certificate for you.)
State of: _________________________ County of: _________________________
My Name is: (print name) ________________________________________.
I am eligible, by law, to receive the birth certificate requested below, because I am the: (check one)
___ Child named on the birth certificate, and of legal age (18)
___ Parent listed on the child’s birth certificate
___ Legal Guardian of the child named on the birth certificate
___ Legal Representative of the child or parent named on the birth certificate
I authorize the Department of Health, Office of Vital Statistics to issue the birth certificate of:
___________________________________ to ___________________________________.
(Child named on birth certificate) (Print name of person to receive birth certificate)
(Required) I have attached a photocopy of my valid photo ID:
______________________________ .
Type of Identification attached (If attorney, only bar number required)
NOTE: Pursuant to s. 382.026, Florida Statutes, it is a 3
rd
degree felony to obtain and use a Florida birth record
fraudulently, punishable as set forth in s. 775.082, s. 775.083, or s. 775.084, Florida Statutes.
I hereby swear or affirm the above statements are true and correct.
____________________________
Signature of person checked above
Subscribed and sworn before me this ________ day of ____________________, 20____ by
______________________________, who is: __ personally known to me, or, __ who has produced
(Print name of person checked above)
_________________________ as identification. My commission expires: ___________________.
(Type of identification produced)
_________________________ _________________________
(Signature of notary) (Print, type or stamp name of notary) (SEAL)
Even if personally known to the notary, the rules of the Department of Health require the person completing this form to provide
a photocopy of valid photo identification.
