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COUNTY OF LOS ANGELES DEPARTMENT OF PUBLIC HEALTH (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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COUNTY OF LOS ANGELES DEPARTMENT OF PUBLIC HEALTH
313 N. FIGUEROA ST. RM L-1, LOS ANGELES, CA 90012 (213) 288-7812
APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD
(We maintain records of births until the child's first birthday)
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.
I am requesting an A
AUTHORIZED
copy I am requesting an I
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 (primer, segundo, appellido)
CITY OF BIRTH – CIUDAD DE NACIMENTO
NAME OF FATHER – NOMRE DEL PADRE
MAIDEN NAME OF MOTHER – NOMBRE DE SOLTERA DE LA MADRE
RELATIONSHIP TO REGISTRANT (SEE ABOVE) - PARENTESCO CON LAS PERSONA REGISTRADA (VEASE ARRIBA)
I ____________________________________ swear (or
affirm) under penalty of perjury that I am an
authorized person, as defined in California Health and Safety Code Section 103525(c), and am eligible
to receive an AUTHORIZED certified copy of the birth record identified on this application form.
Sworn this ______ day of __________________, _________ at ______________________________
Signature__________________________________________________
DL/ID________________________
NAME/NOMBRE
STREET ADDRESS/NUMERO Y CALLE
CITY /CIUDAD STATE/ESTADO ZIP/ZONA POSTAL
FOR DPH USE ONLY
Receipt/Log #
BNPNS#
Phone Number________________________
Rev. 7/19
Those who are not authorized may receive an INFORMATIONAL Certified Copy with the words "INFORMATIONAL, NOT A
VALID DOCUMENT TO E
STABLISH IDENTITY" imprinted across the face of the copy.
MAIL REQUESTS FOR AUTHORIZED COPIES MUST BE ACCOMPANIED BY A NOTARIZED CERTIFICATE OF IDENTITY
Complete your name and mailing address below. -
Escriba abajo su nombre y direccion.
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.
Rev. 7/19
COUNTY OF LOS ANGELES DEPARTMENT OF PUBLIC HEALTH
313 N. FIGUEROA ST. RM L-1, LOS ANGELES, CA 90012 (213) 288-7812
APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD
(We maintain records of births until the child's first birthday)
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.
Rev. 7/19
I am requesting an AAUTHORIZED copy I am requesting an IINFORMATIONAL copy
AGE LAST BIRTHDAY – EDAD CUMPLIDA NUMBER OF COPIES
NUMERO DE COPIAS
Date of Birth – Fecha De Nacimiento
NAME GIVEN AT BIRTH (first, middle , last) –NOMBRE DE NACIMIENTO (primer, segundo, appellido)
CITY OF BIRTH – CIUDAD DE NACIMENTO
NAME OF FATHER – NOMRE DEL PADRE
MAIDEN NAME OF MOTHER – NOMBRE DE SOLTERA DE LA MADRE
RELATIONSHIP TO REGISTRANT (SEE ABOVE) - PARENTESCO CON LAS PERSONA REGISTRADA (VEASE ARRIBA)
I ____________________________________ swear (or affirm) under penalty of perjury that I am an
authorized person, as defined in California Health and Safety Code Section 103525(c), and am eligible
to receive an AUTHORIZED certified copy of the birth record identified on this application form.
Sworn this ______ day of __________________, _________ at ______________________________
Signature__________________________________________________
DL/ID________________________
NAME/NOMBRE
STREET ADDRESS/NUMERO Y CALLE
CITY /CIUDAD STATE/ESTADO ZIP/ZONA POSTAL
FOR DPH USE ONLY
Receipt/Log #
BNPNS#
Phone Number________________________
Those who are not authorized may receive an INFORMATIONAL Certified Copy with the words "INFORMATIONAL, NOT A
VALID DOCUMENT TO E
STABLISH IDENTITY" imprinted across the face of the copy.
MAIL REQUESTS FOR AUTHORIZED COPIES MUST BE ACCOMPANIED BY A NOTARIZED CERTIFICATE OF IDENTITY
Complete your name and mailing address below. -
Escriba abajo su nombre y direccion.
Month/Mes Day/Dia Year/Año
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COUNTY OF LOS ANGELES DEPARTMENT OF PUBLIC HEALTH (County of Los Angeles Internal Services Department)

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Completed 27 September 2020

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