Fillable MAIL APPLICATION FOR BIRTH RECORD (Texas Real Estate Contracts)

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MAIL APPLICATION FOR BIRTH RECORD (Texas Real Estate Contracts)

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The MAIL APPLICATION FOR BIRTH RECORD (Texas Real Estate Contracts) form is 2 pages long and contains:

  • 2 signatures
  • 18 check-boxes
  • 67 other fields

Country of origin: US
File type: PDF

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The Texas Real Estate Commission (TREC) is an agency that governs real estate practices in the state of Texas USA. I its headquarters are located in Ausin Texas at 1700 North Congress.

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Texas
Department
of
State
Health
Services
_______________________________
__________________________________________________________
OFFICE USE ONLY
☐ CHECK ☐ MONEY ORDER
REMITTANCE NO. ______________CERT. #_______________________
DATE ______________________ AMOUNT $_____________________
DOCUMENT CONTROL # ______________________________________
MAIL APPLICATION FOR BIRTH RECORD
PLEASE PRINT CLEARLY.
INCLUDE A COPY OF YOUR (APPLICANT) VALID ID WHEN SENDING IN THE REQUEST. APPLICATION MUST BE ORIGINAL
(INCLUDING SIGNATURE). NO CROSS OUT OR WHITE OUT WILL BE ACCEPTED. SEE INSTRUCTIONS ON BACK.
Step
1: YOUR INFORMATON AND SHIPPING ADDRESS (PLEASE PRINT)
Your Name (First, Middle, Last Name):
Street Address:
City:
State:
Zip Code:
Daytime
Phone Number:
Your relationship to Person named on Certificate (Check One): ☐ Self
☐
Child
☐
Spouse
☐
Parent
☐
Sibling
☐
Grandparent
☐
Legal Guardian (proof required)
☐
Legal Representative (proof required)
☐
Other:_______________________
☐ I authorize mailing to the address below instead of my mailing address listed above.
Name:
Address to Send to if different than noted above:
City:
State:
Zip Code:
Reason for Request:
☐ Newborn ☐ Travel/Passport ☐ Records ☐ School ☐ Insurance ☐ Other: _______________________________
Step 2: INFORMATION FOR PERSON NAMED ON BIRTH RECORD (Must be completed to Identify Record Requested)
FULL NAME
ON RECORD:
First Name
Middle Name
Last Name
DATE OF
BIRTH:
Month
Day
Year
SEX:
PLACE OF
BIRTH:
City or Town
County
TEXAS ONLY
FULL NAME OF
PARENT 1:
First Name
Middle Name
Maiden Last Name
(Before first marriage)
FULL NAME OF
PARENT 2:
First Name
Middle Name
Maiden Last Name
(Before first marriage)
Step 3: COST & FEES (NOT REFUNDABLE, if Record Not found) | Step 4: AFFIDAVIT (NOTARY SECTION)
Select Record Type:
Qty
Price/each
Total
☐ Long Form Birth Certificate
(Travel/Passport)
x $22.00
$
☐ Short Form Birth Certificate (General Use)
x $22.00
$
☐ Texas Flag Heirloom Birth Certificate
(Framing and Display)
x $60.00
$
☐ Bassinet Heirloom Birth Certificate
(Framing and Display)
x $60.00
$
☐ Birth Verification (Letter, not official
certificate)
x $22.00
$
☐ Military Personnel with current
deployment orders
Exempt
☐ Foster or Homeless child or youth
Exempt
For urgent requests, orders may
be EXPEDITED by sending the order through an
overnight mail service, such as: FEDEX,
LoneStar, or UPS to our physical address:
DSHS – VSS MC 2096, 1100 W. 49th St., Austin, TX 78756
and paying the
below expedited processing fee.
☐
Expedited Processing (estimated 20-25 business days)
$5.00
All orders are returned free of charge by USPS regular mail. For expedited return
mail service, select
one
of the overnight return shipping methods below
.
☐
Overnight Return Mail (for shipping within USA)
$8.00
☐
USPS Express Return Mail (for shipping to PO Box ONLY)
$22.95
☐ 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.
$5.00
Total
Due:
$
ONLY applications for birth certificates (NOT birth
verifications) submitted by mail need to be notarized
STATE OF _________________________
COUNTY OF________________________
This instrument was acknowledged before me
on________________
(Date)
By________________________________________
(Printed Name of applicant acknowledging)
(Notary Public’s Signature)
(Personalized Seal)
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.)
READ & SIGN (Applications without signatures or attached valid ID will NOT be accepted for processing)
Signature of Applicant __________________________ Date Signed (MM/DD/YYYY) _____/_____/_________
VS – 140 (1/21)
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TEXAS
Health
and
Human
Texas
Department
of
State
Services
Health
Services
MAIL APPLICATION FOR BIRTH RECORD
Processing times are estimates and subject to change with an increased volume of customer applications.
FAILURE TO PROVIDE INFORMATION REQUESTED ON THIS FORM MAY RESULT IN SIGNIFICANT
PROCESSING DELAYS AND/OR DENIAL OF YOUR APPLICATION.
Walk In: Same day service in most cases. Hours are Monday-Friday 8:00 am - 4:00 pm. DSHS - Vital Statistics Section, 1100 W. 49th
St., Austin, TX 78756
Online Orders:
Visit
www.texas.gov
to order online. Online orders are mailed 15-20 business days after receipt of the request.
Mail In Orders: Processed and mailed 6 - 8 weeks after receipt of the request. Mail to: DSHS - VSS, P.O. Box 12040, Austin, TX
78711-2040. For current processing times, please see our website at: https://www.dshs.texas.gov/vs/processing/.
Expedited Orders:
Processed and mailed 20 - 25 business days after receipt of the request. Must be sent to the Texas Department
of State Health Services - Vital Statistics Section via an OVERNIGHT mail service, such as FedEX, LoneStar, or UPS to: DSHS – VSS
MC 2096, 1100 W. 49th St., Austin, TX 78756
Long form Birth Certificate - Most comprehensive birth record. It is a copy of the original birth certificate. It will also show a history of
corrections that have been made to the birth record. This form is often used for requesting passports.
Short form Birth Certificate - An abstract of the birth record. This birth certificate will only show current information for the child's
name, date of birth, place of birth, sex, and name of parent(s). This form will not show a history of corrections. This form is often
used for school records and is acceptable for most purposes.
Heirloom birth certificate - Heirloom birth certificates are abstracts of the birth record. They are primarily used for framing and
display. The information on an "heirloom birth certificate" is similar to a "short form". Examples of heirloom birth certificates can
be seen on our website at http://www.dshs.texas.gov/reqproc/heirloom.shtm.
Verification Letter - A verification letter will include the child’s name, the date of birth, and the county where the birth occurred.
Verification letters are available for births that have occurred since 1903. Verification letters are not considered legal substitutes
for certified copies of birth certificates. The VSS strongly recommends that applicants ensure a verification will satisfy its
intended use.
Military Personnel with current deployment orders – Texas Government Code 437.217. EXEMPTION FROM FEES FOR MILITARY
PERSONNEL. A member of the National Guard on federal active duty, or a member of the armed forces of the United States on
active duty, who is preparing to be deployed to serve in a hostile fire zone as designated by the United States secretary of defense
is exempt from paying the following state or local governmental fees the member incurs because of the deployment to arrange
the member's personal affairs: (1) fees for obtaining copies of: (A) a birth certificate. MILITARY ID AND MILITARY ORDERS ARE
REQUIRED.
Foster or Homeless child or youth – Texas Health and Safety Code 191.0049. BIRTH RECORD ISSUED TO FOSTER CHILD OR
YOUTH OR HOMELESS CHILD OR YOUTH. On request of a child or youth described by this section, the state registrar, a local
registrar, or a county clerk shall issue, without fee or parental consent, a certified copy of the child's or youth's birth record to:
(1) a homeless child or youth as defined by 42 U.S.C. Section 11434a; (2) a child in the managing conservatorship of the
Department of Family and Protective Services; and (3) a young adult who: (A) is at least 18 years of age, but younger than 21
years of age; and (B) resides in a foster care placement, the cost of which is paid by the Department of Family and Protective
Services. DOCUMENTATION OF STATUS IS REQUIRED.
Copies of birth certificates for births that occurred within the past 75 years can be requested only by the immediate family
of the person whose name is on the birth certificate. See Section 181.1(13) of the Texas Administrative Code for who qualifies as
an immediate family member. An immediate family member is the child, their guardian, their children, spouses, parents,
siblings, or grandparents.
Applicants who are not immediate family members must provide legal documentation (such as a court order establishing
guardianship) that demonstrates a direct, tangible interest in the birth certificate.
The applicant must include a copy of his or her valid photo ID issued by a governmental entity. See Section 181.28 of the
Texas Administrative Code for a complete list of acceptable forms of identification. You also can see VSS’s page
on acceptable identification in English (http://www.dshs.texas.gov/vs/reqproc/Acceptable-IDs/) and Spanish
(http:// www.dshs.texas.gov/vs/reqproc/Acceptable-IDs-(Spanish)/).
If a record is not on file, our office will issue a “not found” letter.
Custo
mer Checklist
☐ Complete steps 1, 2, and 3 of the application. Please type or print clearly.
☐ Complete step 4 of the application and have it notarized, if requesting a birth certificate.
☐ Sign and date the application.
☐ Make sure the application is original and not a photocopy and there are no cross-outs or white-out.
☐ Enclose a copy of a current driver's license, passport or state identification. See complete ID list on our website.
☐ Enclose appropriate fees. Make checks or money orders payable to DSHS – Vital Statistics.
For more information, go to: https://www.dshs.texas.gov/vs/requirements.aspx.
For the status of your request, contact VSS by telephone at 1-888-963-7111 or online at: https://www.dshs.texas.gov/orderstatus/.
VS – 140 (1/21)
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MAIL APPLICATION FOR BIRTH RECORD (Texas Real Estate Contracts)

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Completed 4 March 2021

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