Fill - Free fillable Pleasecompletethe FOROFFICIALUSEONLY NOTAVALIDDOCUMENTTOESTABLISHIDENTI TY. copy will receive an (County of San Diego) PDF form

VRBC 01/2020

Page1of2

Ifwecannotidentifytherecordbasedontheinformationyouprovided,StateLawrequiresthatweretainthefeeandissuea“LetterofNo

Record”.

 IwouldlikeanAuthorizedCertifiedCopyoftherecordidentified

on the application form.(In order 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.)

 I would like an Informational Certified Copy of the record

identifiedonthe applicationform.(Youarenotrequiredto

select from the list below or complete the statement of

identity.)

Iam:  Theregistrantoraparentorlegalguardianoftheregistrant.

 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.

 Apartyentitledtoreceiverecordsasaresultofacourtorder,oranattorneyoralicensedadoptionagencyseekingthe

birthrecordinordertocomplywithrequirementsofSection3140or7603oftheFamilyCode.

APPLICANTINFORMATION(PLEASEPRINTORTYPE)

NameofPersonCompletingApplication Today’sDate TelephoneNumber–(AreaCodeFirst)

Address–Number,Street City State ZIPCode

BIRTHCERTIFICATEINFORMATION(PLEASEPRINTORTYPE)

Mother’smaidenname

Nameofchild(First) Middle Last(Family) DateofBirth

NumberofCopies

Requested:

COUNTYUSEONLY:

Year___________________ Registration#_________________________

BC_______________$__________________

SearchFee_______$____________

ReceiptSignature_______________________ BN#__________________________ BY:_________DATE:_______________

CountyofSanDiego‐HealthandHum

anServicesAgency

PublicHealthServices‐OfficeofVitalRecordsandStatistics

APPLICATIONFORABIRTHCERTIFICATE

ORCERTIFICATIONOFNOPUBLICRECORD

$28.00FeeperCertificate

Per California State Law, Health and Safety Code, Section 103526(c), permits

onlyauthorizedpersonsasdefinedbelowtorequestauthorizedcertifiedcopies

of Birth Records. Those who are not authorized by Law to receive a certified

copy will receive an informational certified copy marked “INFORMATIONAL,

NOTAVALIDDOCUMENTTOESTABLISHIDENTI

TY.”

FOROFFICIALUSEONLY

Typeofidentificationprovided,ifprocessedinperson:

 Driver’sLicense

 Passport

 MilitaryID

 Other

______________

Pleasecompletethe

reverseofthispage

SWORN STATEMENT

I, ______________________________________________, declare under penalty of perjury under the laws of the State of California, that I am

(Print Name)

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 record of the following individual(s):

Name of Person Listed on Certificate

Number of

Copies

Applicant’s Relationship to Person Listed on Certificate

Subscribed to this _______ day of ______________, 20_____, at ________________________________, ________________.

(Day) (Month) (Yr) (City) (State)

______________________________________________________

(Applicant’s Signature)

Note: If submitting your order by mail and requesting a Certified Copy, you must have your sworn statement notarized using the Certificate of

Acknowledgment below. The notary is only verifying the identity of the person requesting the copy not the relationship to the registrant.

Only one notarization is required even though the requestor may have a different authorized relationship to each being requested, (i.e. Mother on one

request, Registrant on another request, etc.).

CERTI

FICATE OF ACKNOWLEDGMENT

Stat

e of _______________________________ County of _____________________________________________________

On _____

__________________________ before me, ________________________________________________________, Notary Public,

(Insert name of the officer)

Personally appeared _____________________________________ 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

Personally Known OR Produced Identification.

Type of Identification produced _________________________

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 to the truthfulness, accuracy, or validity of that document.

Please mail this request along with your payment (check or money

order payable to County of San Diego Public Health Services) to:

Office of Vital Records

3851 Rosecrans St. - Suite 802 MS -P529

San Diego, CA 92110

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