Fillable NEED A BIRTH CERTIFICATE? (HSA)

Fill Online, Printable, Fillable, Blank NEED A BIRTH CERTIFICATE? (HSA) Form

Use Fill to complete blank online HSA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

NEED A BIRTH CERTIFICATE? (HSA)

On average this form takes 13 minutes to complete

The NEED A BIRTH CERTIFICATE? (HSA) form is 3 pages long and contains:

  • 0 signatures
  • 2 check-boxes
  • 51 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your HSA forms online.

BROWSE HSA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
HSA 884-2 Revised 12/23/2019
NEED A BIRTH CERTIFICATE?
APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD
DO NOT Complete the Application Before Reading the Instructions!
1. Complete a separate application form for each person whose birth record is requested.
2. An Authorized Certified Copy of a birth record will establish the identity of the registrant. An Informational
Certified Copy contains the same information, but will not establish the identity of the registrant. California law
permits only specified persons (as listed on the application) to receive Authorized Certified Copies of birth
records. All others may only receive an Informational Certified Copy, marked with the legend “Informational,
Not a Valid Document to Establish Identity.”
3. In the top section of the application, specify whether you are requesting an Authorized Certified Copy or an
Informational Certified Copy. If you are requesting only an Informational Certified Copy, you do not need to mark
any of the five options on the list or submit the sworn statement on the last page; just complete the “Applicant
Information” and “Birth Certificate Information” sections.
4. Complete the Applicant Information section and provide your printed name and your signature where
indicated. Complete the Birth Certificate Information section, providing all the information you can. Be sure to
give the registrant’s full name. If the information you furnish is incomplete or inaccurate, we may not be able to
find the record. If the registrant has been adopted, please make the request in the adopted name. (If you are
requesting a copy of the original sealed birth certificate, you must apply to the State Office of Vital Records with
a court order releasing the original sealed record.)
5. SWORN STATEMENT:
For an Authorized Certified Copy (which is needed in order to get a driver’s license, passport, Social Security
card, etc.), you must complete the top section of the application, identifying your relationship to the registrant,
and you must sign the attached sworn statement.
If you apply in person, you must sign the sworn statement in the presence of the Office of Vital Records staff.
If you mail your request, your sworn statement and signature must be notarized by a Notary Public. (To find a
Notary Public, see your local yellow pages or contact your banking institution.) Any request for an Authorized
Certified Copy that does not include a notarized sworn statement will be returned without processing. Law
enforcement and local and state government agencies are exempt from the notary requirement.
PLEASE NOTE: Only one notarized sworn statement is required for multiple certificates requested at the same
time; however, the sworn statement must include the name of each individual whose birth certificate you wish to
obtain and your relationship to that individual.
6. Submit $28 (cash, check or money order ONLY) for each Authorized Certified Copy or Informational
Certified Copy requested. Indicate the number of copies you want and which type you want, and include
sufficient payment with this application, in the form of a personal check or a postal or bank money order
(International Money Order for out-of-country requests) made payable to HSA Vital Statistics.
7. Submit this application with the sworn statement and payment (cash, check, or money order only) to:
(in person) (by mail, with sworn statement notarized)
Office of Vital Records Office of Vital Records
1430 Freedom Boulevard, Suite A P.O. Box 962
Watsonville CA 95076 Santa Cruz CA 95061
You must complete the application with the correct address information in order to insure prompt processing.
For births BEFORE 2018, don’t use this form. Contact the County Recorder’s Office, 701 Ocean Street #230,
Santa Cruz CA 95060; http://www.co.santa-cruz.ca.us/rcd/recorders/birth&death/maincertificates.htm;
831/454-2800.
If the birth occurred over six weeks ago, you can also order a birth certificate via the Internet, by logging onto
www.vitalchek.com, using your credit card to process your request, for an additional fee of about $13.
Contact Information: Hours:
(831) 763-8430 Monday-Friday 9:00 am to 4:00 pm
Email: vitalstats@santacruzcounty.us
HSA 884-2 Revised 12/23/2019
APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD
Santa Cruz County Office of Vital Records
DO NOT Complete This Application Before Reading the Instructions!
Please indicate whether you are requesting an Authorized Certified Copy or an Informational Certified Copy.
_________________________________________________________________________________________________________________
□ I would like an Authorized Certified Copy. This copy will establish □ I would like an Informational Certified Copy. This
the identity of the registrant. To receive an Authorized Certified document will be printed with a legend that reads
Copy, you must indicate your relationship to the registrant, by “Informational, Not a Valid Document to Establish Identity.”
selecting from the following list, and complete the attached sworn For an Informational Certified Copy, you are not required
statement. If applying by mail, you must have the sworn statement to select from the list below or submit the sworn notarized
notarized (unless you are with a law enforcement agency or a state statement; just complete the “Applicant Information” and
or local government agency). “Birth Certificate Information” below.
______________________________________________________________________________________________________
I am (check one):
□ The registrant 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 government 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. (If you are requesting an Authorized Certified Copy under a power of attorney,
include a copy of the power of attorney with this application form.)
BIRTH CERTIFICATE INFORMATION (PLEASE PRINT OR TYPE)
Child’s First Name on Certificate
Child’s Middle Name on Certificate
Child’s Complete Last Name on Certificate
City or Town of Child’s Birth
County of Child’s Birth
Date of Birth – Month, Day, Year (If unknown, enter approximate date of birth)
Sex
Female Male
Father‘s First Name on Certificate
Father’s Middle Name on Certificate
Father’s Last Name on Certificate
Mother’s First Name on Certificate
Mother’s Middle Name on Certificate
Mother’s Maiden Name
APPLICANT INFORMATION (PLEASE PRINT OR TYPE)
Today’s Date
Telephone Number – Area Code First
( )
Mailing Address – Number, Street
City
State
ZIP Code
Name of Person Receiving Copies, if Different From
Above
No. of Copies
Amount Enclosed
$
E-mail Address
Mailing Address for Copies, If Different From Above
City
State
ZIP Code
BIRTH
HSA 884-2 Revised 12/23/2019
SWORN STATEMENT
I, ___________________________________, declare, under penalty of perjury under the laws of the State of California,
(Your Printed Name)
that I am an authorized person, as defined in California Health and Safety Code Section 103526 (c), and am eligible to receive a
certified copy of the birth or death record of the following individual(s):
Name of the Child Listed on the Certificate
Your Relationship to the Child Listed on the Certificate
(The information below must be completed in the presence of Office of Vital Records staff or a Notary Public.)
Declared this ________ day of ____________________, 2020, at _____________________________________, __________.
(Day) (Month) (City) (State)
______________________________________________________
(Your Signature)
Note: If submitting your order by mail, you must have your sworn statement notarized, using the Certificate of
Acknowledgment below. The Certificate of Acknowledgment must be completed by a notary public. (Law
enforcement and local and state government agencies are exempt from the notary requirement.)
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
CERTIFICATE OF ACKNOWLEDGMENT
State of _______________________)
) ss
County of ______________________)
On _________________________, before me, _______________________________________, personally appeared
(here insert name and title of the officer)
________________________________________, who proved to me on the basis of satisfactory evidence to be the person whose
name is subscribed to the within instrument, and acknowledged to me that he/she executed the same in his/her authorized capacity,
and that by his/her signature on the instrument the person, or the entity upon behalf of which the person 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 SEAL)
__________________________________________
NOTARY SIGNATURE
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.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

NEED A BIRTH CERTIFICATE (HSA)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 21 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document