66 Montgomery County Clerk
Mark Turnbull
BIRTH CERTIFICATE APPLICATION
PLEASE TYPE OR PRINT. APPLICATION MUST BE ORIGINAL (INCLUDING
SIGNATURE). NO CROSS OUT OR WHITE OUT WILL BE ACCEPTED. INCLUDE A
PHOTOCOPY OF YOUR VALID I.D. WHEN SENDING IN THE REQUEST BY MAIL.
STEP 1: YOUR INFORMATION AND MAILING ADDRESS (PLEASE PRINT)
Your Name: (first, middle, last name, suffix):
Your relationship to the person named on the certificate:
I authorize mailing to the address below, if mailing to address other than address listed above:
Name: (first, middle, last name, suffix):
STEP 2: INFORMATION FOR THE PERSON NAMED ON THE BIRTH CERTIFICATE (PLEASE PRINT)
Full Name on Certificate
(First, Middle, Last Name, Suffix):
Parent 1: First, Middle, Last name prior to first marriage (maiden name)
Parent 2: First, Middle, Last name prior to first marriage (maiden name)
STEP 3: COST & FEES (FEES NON-REFUNDABLE)
CASH, CHECK OR
MONEY ORDER
PLEASE
DO NOT
MAIL CASH
Long Form Certificate (Montgomery County only)
Military Personnel with current deployment orders
----------EXEMPT----------
I wish to make a voluntary contribution of $5.00 to promote healthy early childhood by supporting the Texas Home Visitation
Program administered by the Office of Early Childhood Coordination of Health and Human Services.
STEP 4: ACKNOWLEDGMENT – If you are submitting the application by mail, you must have it notarized before mailing it in.
STATE OF Texas
COUNTY of ___________________________________________
(seal
)
This instrument was acknowledged before me on
(name of person acknowledging)
Notary Public or Deputy Clerk
WARNING: IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY
MAKING A FALSE STATEMENT ON THIS FORM OR SIGNING A FORM WHICH CONTAINS A FALSE STATEMENT IS 2
TO 10 YEARS IMPRISONMENT AND A FINE OF UP TO $10,000. (HEALTH AND SAFETY CODE, CHAPTER 195, SEC. 195.003.)
Birth Certificate Number:
This is a fillable form. You must have it notarized if you are applying by mail.