P. O. Box 480 Security Paper:_____________
Belton, Texas 76513 LFN:_____________________
(254) 933-5165
Application for Birth or Death Certificate
Shelley Coston, Bell County Clerk
BIRTH CERTIFICATES DEATH CERTIFICATES
_____Certified Copies X $23.00____ ______ Certified Copies X $21.00______
_____Additional Copies X $4.00_______
Make Cashier’s Check or Money Orders payable to: Bell County Clerk *No Out of State checks will be accepted*
I wish to make a voluntary contribution of $5.00 to promote healthy early childhood by supporting the Texas Home Visitation Program
IDENTIFY BIRTH OR DEATH RECORD INFORMATION (Part I)
Full Name of Person
on Record
First Name
Middle Name
Last Name (Maiden Name)
Date of Birth or Death
Month
Day
Year
Place of Birth or
Death
City or Town
County
Sex
Full name of Parent
First Name
Middle Name
Last Name (Maiden Name)
Full Name of Parent
First Name
Middle Name
Last Name (Maiden Name)
APPLICANT INFORMATION (Part II)
Applicant’s Name
Telephone #
Email Address
Full Mailing Address Street Address City State Zip
Purpose for obtaining this record
I authorize mailing to the address below. I have verified that the address below will receive my order
Name of Person Receiving Copies, if Different from Applicant
Mailing Address for Copies, If Different from Applicant
City
State
Zip
AFFIDAVIT OF PERSONAL KNOWLEDGE (MUST BE SIGNED IN PRESENCE OF NOTARY PUBLIC) (Part III)
STATE OF ______________ COUNTY OF______________ Before me on this day appeared_________________________________________ now
(Applicant’s Name)
residing at ______________________________________________________________________________________________________________
(Address) (City) (State) (Zip)
who is related to the person name on Part I as _______________________________________________ and who on oath deposes and says that
the contents of this affidavit are true and correct.
The applicant presented the following type and number of Identification: ___________________________________________________
Applicant signature_____________________________________________
Sworn to and subscribed before me, this _____ day of_______________________, 20_______
Signature of Notary Public and Notary ID Number_____________________________________
Typed or Printed Name _________________________________________________________
Commission Expires ___________________________________________________________
Street Address________________________________________________________________
City, State, Zip________________________________________________________________
WARNING: IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT ON THIS FORM OR FOR 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)
MAIL THIS APPLICATION, PAYMENT, AND PHOTOCOPY OF YOUR VALID PHOTO ID TO:
Bell County Clerk, Attn: Vital Records Department
P.O. Box 480, Belton, Texas 76513
***ALL PURCHASES ARE FINAL. CLERKS OFFICE IS NOT RESPONSIBLE FOR MISDIRECTED MAIL***
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