Applicant’s Name: ________________________________________________________________________________
STACEY KEMP, COUNTY CLERK
Application for Certified Copy of Birth or Death Certificate
BIRTH - $23.00 Each
NUMBER REQUESTED _____
DEATH - NUMBER REQUESTED
____$21.00 1
st
Certified Copy
____$ 4.00 each additional copy ordered at this time
Full name on record: ______________________________________________________________________________
First Middle Last
Date of Birth or Death: ____________________________ County of Birth or Death: ___________________________
Father/Parent 1: __________________________________________________________________________________
First Middle Last
Mother/Parent 2: _________________________________________________________________________________
First Middle Last (Maiden)
Daytime Phone Number: ____________________________ Email Address: ________________________________
Applicant’s Mailing Address: ________________________________________________________________________
Street City State Zip
Relationship to person named on certificate: ___________________________________________________________
Purpose for obtaining copy of certificate: Please check all that apply.
____Driver License ____Housing ____Insurance ____Passport ____Records
____School ____Social Security ____Travel ____Veterans ____Welfare
Other, please specify:____________________________________________________________________________
______________________________________________________________________________________________
NOTICE: Providing false information on this application is a violation of the law and may lead to fine or imprisonment, or both. The person to whom any certified copy of Birth or Death Record is
issued must be a properly qualified applicant. The applicant must have a direct and tangible interest in the record and further, should have a significant legal relationship to the person whose record is
requested. The purpose for which the certified copy is needed and the relationship of the applicant to the registrant is essential to determination as to whether or not the person making the request is a
properly qualified applicant. (Health and Safety Code, Chapter 678, Sec. 196.003)
Witness my/our hand(s) this_____________________day of _________________________________, 20_____.
Signature of Applicant_____________________________________________________________
THE STATE OF ________________________ }
COUNTY OF __________________________ }
BEFORE ME, ______________________________________________, (SEAL)
in and for said County and State, on this day personally appeared
__________________________________________________________,
known to me to be the person(s) whose name subscribed to the foregoing
instrument, and acknowledged to me that he/she/they executed the same
for the purpose therein expressed.
Given under my hand and seal of office, this ____________________day of ____________________, 20_____.
____________________________________________
Printed Name of Notary
____________________________________________
Signature of Notary
Mail this application, payment and a legible photocopy of your VALID Government Issued Photo ID.
If payee is different from applicant, you must submit a copy of the Valid ID of BOTH parties.
REQUEST WILL NOT BE PROCESSED WITHOUT ID INFORMATION
2300 Bloomdale Road, Suite 2106
McKinney, TX 75071
972.548.4185
900 East Park Boulevard, Suite 140C
Plano, TX 75074
972.881.3025/3029
OFFICE USE ONLY
Volume________ Page________ Check________ Cash________
Austin File No._________________ Security Paper_______________ Money Order_______ Debit/Credit Card ________
Questions: ctyclerks@collincountytx.gov
