Fillable APPLICATION FOR BIRTH RECORD (County of Los Angeles / Internal Services Department)

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APPLICATION FOR BIRTH RECORD (County of Los Angeles / Internal Services Department)

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BROWSE COUNTY OF LOS ANGELES / INTERNAL SERVICES DEPARTMENT (CA) FORMS

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LOS ANGELES COUNTY y REGISTRAR-RECORDER/COUNTY CLERK, P.O. BOX 489, NORWALK, CA 90651-0489 (562) 462-2137
APPLICATION FOR BIRTH RECORD
Pursuant to Health and Safety Code 103526, the following individuals are entitled to an AUTHORIZED Certified Copy
of a birth record.
◈ The registrant or a parent or legal guardian of the registrant
◈ A party entitled to receive the record as a result of a court order, or an attorney or a licensed adoption
agency seeking the birth record in order to comply with the requirements of Section 3140 or 7603 of the
Family Code.
◈ A member of a law enforcement agency or a representative of another governmental agency, as provided
by law, who is conducting official business.
◈ A child, grandparent, grandchild, sibling, spouse or domestic partner of the registrant
◈ An attorney representing the registrant or the registrant's estate, or any person or agency empowered by
statute or appointed by a court to act on behalf of the registrant or the registrant's estate.
If applying in person the application must be signed in the presence of the cashier.
Those who are not authorized may receive an INFORMATIONAL Certified Copy with the words
"INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY" imprinted across the face of the
copy.
MAIL REQUESTS FOR AUTHORIZED COPIES MUST BE ACCOMPANIED BY A NOTARIZED CERTIFICATE OF IDENTITY
I am requesting an AUTHORIZED copy I am requesting an INFORMATIONAL copy
AGE LAST BIRTHDAY – EDAD CUMPLIDA NUMBER OF COPIES
NUMERO DE COPIAS
Month/Mes Day/Dia Year/Año
Date of Birth – Fecha De Nacimiento
NAME GIVEN AT BIRTH (first, middle , last) –NOMBRE DE NACIMIENTO (primero, segundo, apellido)
CITY OF BIRTH – CIUDAD DE NACIMENTO
NAME OF FATHER – NOMBRE DEL PADRE
MAIDEN NAME OF MOTHER – NOMBRE DE SOLTERA DE LA MADRE
RELATIONSHIP TO REGISTRANT (SEE ABOVE) - PARENTESCO CON LAS PERSONA REGISTRADA (VEÁSE ARRIBA)
I ____________________________________ certify (or declare) under penalty of perjury under the laws of
the State of California that the foregoing is true and correct.
Date ___________________________ Signature__________________________________________________
DL/ID________________________
NAME/NOMBRE
STREET ADDRESS/NUMERO Y CALLE
CITY /CIUDAD STATE/ESTADO ZIP/ZONA POSTAL
76A639B Rev. 5/10
FOR RECORDER USE ONLY
File Number
Searched
Doubled
SPECIAL NOTICE TO VETERANS
You may be eligible for a free certified copy if you are applying for a veteran’s pension or certain other
Veteran’s Administration benefits.
(Section 6107, Government Code State of California)
THIS DOES NOT APPLY TO SOCIAL SECURITY AND OTHER CIVILIAN BENEFITS, EVEN IF YOU
ARE A VETERAN.
If you believe you qualify for a free certified copy under these provisions, complete the following
affidavit.
I hereby apply for a free certified copy of the record as shown on the reverse side and declare under
penalty of perjury that the free copy is to be furnished to
_______________________________________ in a claim for _________________________________
FEDERAL OR STATE AGENCY TYPE OF BENEFIT
___________________ ________________________________________ _____________________
DATE SIGNATURE OF VETERAN OR AUTHORIZED AGENT RELATIONSHIP OF AGENT
NUMBER-STREET
CITY STATE ZIP
Note: The free copy issued on this affidavit will bear the following wording:
This certified copy has been issued free of charge on the declaration under penalty of perjury that it is to be used in
a claim to the Federal Government or the State of California for veteran’s benefits.
76A639B Rev. 5/10
CERTIFICATE OF IDENTITY/SWORN STATEMENT - BIRTH, DEATH & PUBLIC MARRIAGE
In accordance with California State Law, the following identifying information is required to obtain a certified copy of Birth,
Death or Public Marriage Certificate. You must be one of the following to receive an authorized copy of a birth, death or
public marriage record, individual named on certificate, parent, child, legal guardian/custodian, grandparents, grandchild,
sibling, spouse/domestic partner, attorney for individual/estate of individual or representative of an adoption agency (birth
only), funeral director or agent/employee (death only).
This certificate must be signed in the presence of a Notary.
Name(s) on Certificate Relationship
I, , declare under penalty of perjury under the laws of the State of
(Print Name)
California, that I am 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 or death record for the individual(s) listed above.
Subscribed to the day of 20 , at , .
(Day) (Month) (City) (State)
(Signature)
CERTIFICATE OF ACKNOWLEDGEMENT
STATE OF CALIFORNIA )
) ss
County of )
On , before me personally appeared
(Insert name and title of officer here)
DEAN C. LOGAN
Registrar-Recorder/County Clerk
COUNTY OF LOS ANGELES
REGISTRAR-RECORDER/COUNTY CLERK
P.O. BOX 489, NORWALK, CALIFORNIA 90651-0489 - www.lavote.net
“Enriching Lives”
______________________________________, who proved to me on the basis of satisfactory evidence, to be the person
whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her
authorized capacity, and that by his/her signature on the instrument the person, or the entity upon behalf of which the person
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.
(NOTARY SEAL)
___________________________________
NOTARY SIGNATURE
R1995 Rev. 3/2010
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APPLICATION FOR BIRTH RECORD (County of Los Angeles Internal Services Department)

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Completed 2 November 2020

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