Fillable SWORN STATEMENT INSTRUCTIONS (California)

Fill Online, Printable, Fillable, Blank SWORN STATEMENT INSTRUCTIONS (California) Form

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

SWORN STATEMENT INSTRUCTIONS (California)

On average this form takes 6 minutes to complete

The SWORN STATEMENT INSTRUCTIONS (California) form is 2 pages long and contains:

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

Country of origin: US
File type: PDF

BROWSE CALIFORNIA 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
 
State of California – Health and Human Services Agency California Department of Public Health
VS 20 (1/20)
Page 1 of 2
SWORN STATEMENT INSTRUCTIONS
• Only one sworn statement is required for multiple records.
• Sworn statements are not required for informational copy requests.
• Authorized individuals must complete the top portion of the sworn statement by signing and
identifying their relationship to person listed on certificate.
• Sworn statements must be notarized for authorized copy requests. Law enforcement,
governmental agencies, and funeral establishments (death records only) are exempt from the
notary requirement, but must complete the top portion of the sworn statement page.
• A sworn statement notarized by a foreign notary must have an apostille attached. Foreign
notarizations obtained by an Ambassador, Minister, Consul, Vice Consul or Consular Agent of the
United States, or from a Judge of Court of record having a seal in a foreign county do not require
an apostille.
RELATIONSHIP TO REGISTRANT
List of Authorized Persons:
• The registrant or a parent, legal guardian, child, grandparent, grandchild, sibling, spouse, or
domestic partner of the registrant.
• A party entitled to receive the record as a result of court order or an attorney or licensed adoption
agency seeking the birth record in order to comply with the requirements of Section 3140 or
7603 of the Family Code. (Please include a copy of the court order.)
• A member of a law enforcement agency or a representative of another governmental agency, as
provided by law, who is conducting official business. (Companies representing a government
agency must provide authorization from the government agency.)
• Any person or agency empowered by statute or appointed by a court to act on behalf of the
registrant or the registrant’s estate (Include a copy of the power of attorney or documentation
identifying you as executor.)
• An attorney representing the registrant or the registrant’s estate.
• Any agent or employee of a funeral establishment who acts within the course and scope of
employment and on behalf of persons specified in HSC § 7100 (a) (1)-(8).
• Surviving next of kin (As specified in HSC § 7100).
State of California – Health and Human Services Agency California Department of Public Health
VS 20 (1/20)
Page 2 of 2
SWORN STATEMENT
I,
(Applicant’s Printed Name)
, declare under penalty of perjury under the laws of the
State of California, 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, death, or marriage certificate of the following
individual(s):
, .
Regis
trant
(Name of person whose certificate
you are requesting)
Applicant's Relationship to Registrant
(Must be an authorized person)
,
(The remaining information must be completed in the presence of a Notary Public or CDPH Vital Records staff.)
Subscribed to this
(Day)
day of
(Month)
, 20 , at
(City) (State)
(Applicant’s Signature)
CERTIFICATE OF ACKNOWLEDGMENT
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.
State of
County of
On before me,
(Insert name and title 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.
(SEAL)
(SIGNATURE OF NOTARY PUBLIC)
click to sign
signature
click to edit
click to sign
signature
click to edit
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

SWORN STATEMENT INSTRUCTIONS (California)

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 December 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document