Fill - Marin County Recorder 3501 Civic Center Drive, Room

Birth Request Form C1.docx [06/15]

Marin County Recorder

3501 Civic Center Drive, Room 232

San Rafael CA 94903

(415) 473-6094

REQUEST FOR CERTIFIED COPY OF BIRTH RECORD - $25

The fee for vital records must be paid in advance by the applicant. If no record is found, the fee will be retained for searching as

required by California statute, and a “Certificate of No Record Found” will be issued. [H&S 103625, GC 27369]

Birth Certificate Information

Number of Copies Requested

LAST NAME

First Name

Middle Name

Birth Date

City of Birth

County of Birth

Mother’s Maiden Name—Last Name

Mother’s First Name

Mother’s Middle Name

Father’s Last Name

Father’s First Name

Father’s Middle Name

Was the registrant adopted? (Only adopted certificate available.)

□ Yes

Has the registrant’s name changed by court order or amendment?

□ Yes

Requestor Information

E-mail Address

Requestor’s Full Name

Telephone Number

Today’s Date

Address – Number, Street

City

State

Zip Code

Mailing Address for Copies, if Different from Above

City

State

Zip Code

The California Health & Safety Code, Section 103526, permits only authorized persons as defined below to receive authorized certified

copies of birth records. Those who are not authorized by law to receive an authorized certified copy will receive an informational certified

copy marked “INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY”. Please indicate below whether you would

like an Authorized Certified Copy or an Informational Certified Copy.

□

I would like an Authorized Certified Copy of the record

identified on this application form. (To receive an authorized

certified copy, you must indicate your relationship to the person

named on the application form by selecting from the list below

and complete the attached sworn statement.)

□

I would like an Informational Certified Copy of the

record identified on this application form. (You are not

required to select from the list below or complete a

sworn statement in order to receive an informational

certified copy.)

I am:

□

The registrant (person named in the certificate) or a parent or legal guardian of the registrant.

□

A child, grandparent, grandchild, sibling, spouse, or domestic partner 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.

□

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.

For Official Use Only

Book & Page / Document Number:

Bank Note Number(s):

Date Processed:

Processed by:

STOP!

If you are making your request in person, please wait to sign the sworn statement in the presence of a clerk.

IMPORTANT NOTE: If you are submitting your order by mail, you must sign the sworn statement in the presence of a

notary public and the notary public must also fill out the Certificate of Acknowledgment. You may request certified copies for

multiple individuals by mail and collectively notarize them; however, a separate application must be completed for each

request. (A sworn statement is not required to obtain an Informational Certified Copy.)

SWORN STATEMENT

swear under penalty of perjury under the laws of the

(Print Full Name)

State of California, that I am eligible to receive a certified copy of the birth record of the individual

named on the certificate, that my relationship is accurately identified on this request form, and that the

representations made herein are true and correct.

Sworn this

day of

(Day)

(Month)

(Year)

(City)

(State)

(Signature)

CERTIFICATE OF ACKNOWLEDGMENT

State of

County of

before me,

(here insert name and title of the officer)

personally appeared ,

(name of individual appearing)

who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are

subscribed to the within instrument and acknowledged to me that he/she/they executed the same in

his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s),

or the entity upon behalf of which the person(s) acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing

paragraph is true and correct.

WITNESS my hand and official seal.

(Notary Signature)

(SEAL)

All requests must be accompanied by payment in the form of a cashier’s check, money order, or imprinted check drawn on

a California bank. OUT-OF-STATE CHECKS WILL NOT BE ACCEPTED. Make check payable to: “Marin County Recorder.”

To pay by credit card, submit your order through www.vitalchek.com, a third party service provider.

Marin County Recorder

P.O. Box C

San Rafael, CA 94913

A notary public or other officer completing this certificate verifies only the identity of the individual who signed the

document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.

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