Fillable APPLICATION FOR CERTIFIED COPY OF MARRIAGE CERTIFICATE (County of Lake)

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APPLICATION FOR CERTIFIED COPY OF MARRIAGE CERTIFICATE (County of Lake)

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LAKE County Recorder's Office
Vital Records Division
APPLICATION FOR CERTIFIED COPY OF MARRIAGE CERTIFICATE
A new Law effective January 1, 2010 changed the way certified copies of marriage certificates are issued. Certified
copies to establish the identity of a registrant can be issued only to authorized individuals, as indicated below. All
others may receive Certified Informational Copies that are not valid to establish identity.
Fees: $15 per copy (payable to the LAKE County Recorder).
I would like a Certified Copy.
This copy will establish the identity
of the registrant
(To receive a Certified Copy you must indicate
your
relationship to the registrant by selecting from the list below AND
complete the attached Sworn Statement declaring that you are eligible to
receive
the Certified Copy. Your signature on the
Sworn Statement
must be acknowledged by a Notary Public if the application is
submitted by mail,
I would like a Certified Informational Copy
. This document
will be
printed with a legend on the face of the document that
states, "INFORMATIONAL, NOT
A VALID DOCUMENT TO
ESTABLISH IDENTITY."
(A sworn statement does not need to be provided.)
NOTE: Both documents are certified copies of the original document on file with our office. With the exception of
the legend, the documents contain the exact same information
To receive a Certified Copy I am:
The registrant (one of the parties listed on the marriage certificate)
Current Driver's License or#______________
Picture ID and Date of Exp. .________________________
Parent or legal guardian of the registrant.
A member of a law enforcement agency or a representative of another governmental agency, as provided by law, who is conducting
official business. (Companies representing a government agency must provide authorization from the government agency.)
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 status or appointed by a court to act on
behalf of the registrant or the registrant’s estate. (If you are requesting a Certified Copy under a power of attorney, please include a copy of the power
of attorney with this application form.)
DO NOT COMPLETE THE REST OF THIS FORM BEFORE READING THE DETAILED INSTRUCTIONS ON PAGE 3.
APPLICANT INFORMATION
(PLEASE PRINT OR TYPE)
Printed Name and Signature of Person Completing Application Today's Date Telephone Number
( )
Address - Number, Street
City State
ZIP Code
Name of Person Receiving Copies, if Different From Above
No. of Copies Amount Enclosed
Purpose of Request
Mailing Address for Copies, If Different From Above
City
State ZIP Code
MARRIAGE CERTIFICATE INFORMATION (PLEASE PRINT OR TYPE)
NAMES
OF
BOTH PARTIES
TO THE
MARRIAGE
First Name Middle Name Last Name
First Name Middle Name Last Name
Date of Marriage- Month, Day, Year
County Where License was Issued County of Marriage
FOR OFFICIAL USE ONLY
Date copy issued
Clerk Initials
Receipt # Certificate # Type Issued:
Certified Informational
Order Method:
In Person Mail
vs. 113 (01/10/10)
P
age 1 of 3
State of California – Health and Human Services Agency California Department of Public Health
SWORN STATEMENT
I, ___________________________________, declare under penalty of perjury under the laws of the State of California,
(Applicant’s Printed Name)
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, death, or marriage certificate of the following individual(s):
Name of Person Listed on Certificate
Applicant’s Relationship to Person Listed on Certificate
(Must Be a Relationship Listed on Page 1 of Application)
(The remaining information must be completed in the presence of a Notary Public or CDPH Vital Records staff.)
Subscribed to this ______ day of ______________, 20___, at ________________________________, _____________.
(Day) (Month) (City) (State)
______________________________________________________
(Applicant’s Signature)
Note: If submitting your order by mail, you must have your Sworn Statement notarized using the Certificate of Acknowledgment
below. The Certificate of Acknowledgment must be completed by a Notary Public. (Law enforcement and local and state
governmental agencies are exempt from the notary requirement.)
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
CERTIFICATE OF ACKNOWLEDGMENT
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 the truthfulness, accuracy, or validity of that document.
State of _______________________)
County of ______________________)
On ____________before me, _________________________________, personally appeared _______________________________________,
(insert name and title of the officer)
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.
(SEAL)
_________________________________________________________
SIGNATURE OF NOTARY PUBLIC
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INSTRUCTIONS:
1.
As of January 1, 2010,
ONLY
individuals who are authorized by Health and Safety Code Section 103526
can obtain a
Certified Copy
of a Marriage Record. (Page 1 of the application identifies the individuals who are
authorized to make the request.) All others may receive a
Certified Informational
Copy
which will be marked,
"Informational, Not a Valid Document to Establish Identity".
2.
Complete a separate application form for each record of public marriage certificate requested.
3.
Complete the Applicant Information section on the first page of this form and provide your signature
where indicated. Provide all the information you have available to identify the record of the registrant
under
Marriage Certificate Information. If the information you furnish is incomplete or inaccurate, it
may be
impossible to locate the record.
4.
SWORN STATEMENT:
•
The authorized individual requesting the certified copy must sign the attached Sworn Statement,
declaring, under penalty of perjury, that they are eligible to receive the certified copy of the marriage
record and identify their relationship to the registrant.
•
If the application is being submitted by mail, your signature on the Sworn Statement
must be
acknowledged by a Notary Public. (To locate a Notary Public, see your local yellow pages or call your
banking institution.).
•
Any member of a law enforcement agency or a representative of a state or local government
agency, as provided by law, who orders a copy of a record to which subdivision (a) applies in conducting
official business is required to complete the Sworn Statement, however, they may not be required to
have their
signature on the Sworn Statement acknowledged by a Notary Public.
•
If the application is being submitted in person at the County Clerk's Office, the Sworn Statement
must be signed by you in the presence of County Recorder staff, and your signature does not
have to be acknowledged by a Notary Public. You must also provide valid photo
identification to
the County Recorder staff at the time you apply for the copy.
•
A Sworn Statement does not need to be provided if you are requesting a Certified Informational
Copy of the marriage record.
5.
Submit $15 for
each
certified copy requested
If no record of the marriage is found, the $15 fee will be
retained for searching the record (as required by law) and a Certificate of No Public Record will be issued to the
applicant. Indicate the number of certified copies you wish and include the correct fee(s) in the form of a
personal check, postal or bank money order (International Money Order for out-of-country requests) made
payable to the
LAKE County Recorder.
Mail this application with the fee(s) and a self-addressed stamped
envelope to:
Lake County Recorder
255 North Forbes Street
Lakeport CA 95453
(707) 263-2293
Additional applications on available on our website at www.co.lake.ca.us
VS 113 (01/01/10)
MARRIAGE CERTIFICATE
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APPLICATION FOR CERTIFIED COPY OF MARRIAGE CERTIFICATE (County of Lake)

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Completed 18 July 2020

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