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- TEXAS BIRTH CERTIFICATE APPLICATION (Grimes County)

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  • 23 check-boxes
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File type: PDF

U.S.A. forms for Grimes County

BROWSE GRIMES COUNTY (TX) FORMS

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Parent 1: First Middle, Last name prior to first marriage (Maiden Name). Please separate with a space between first, middle and last name.
Place of Birth
Step 1: YOUR INFORMATION AND SHIPPING ADDRESS (PLEASE PRINT)
Your Name (First, Middle, Last Name
, Suffix) Please separate with a space between first, middle and last name.
Step 2 : INFORMATION FOR PERSON NAMED ON BIRTH CERTIFICATE (PLEASE PRINT)
Full Name on Certificate (First, Middle, Last Name, Suffix) Please separate with a space between first, middle and last name.
Street Address
City
State
Zip Code
E-mail Address
Daytime Phone Number
First, Middle, Last Name, Suffix Please separate with a space between first, middle and last name.
Address to Send Certicate to if dierent than noted above
City
State
Zip Code
Other: ____________________________
Reason for Request: Newborn Travel/Passport Records School Insurance
Step 3 : COST & FEES (FEES NON-REFUNDABLE)
Date of Birth Month
Day Year
City
County State
All orders are returned free of charge by USPS regular mail. For urgent requests, orders may
be EXPEDITED by sending the order through an overnight mail service, such as: FEDEX,
LoneStar, or UPS AND selecting one of the overnight return shipping methods below.
Select Certicate Type:
Long Form Birth Certicate
Short Form Birth Certicate
Texas Flag Heirloom Birth Certicate
Bassinet Heirloom Birth Certicate
Birth Verification
Military Personnel with current deployment orders
Qty Price/each Total
x $22.00 $
$
$
$
$
Total Due
$
$27.95
$5.00
$9.95
$13.00
x $22.00
x $60.00
x $60.00
x $22.00
Exempt
Expedite Overnight Mail (for shipping within USA)
$8 for Overnight Mail + $5 for Expedited processing
Priority Mail (for shipping to Overseas Military Address ONLY)
$4.95 for Overnight Mail + $5 for Expedited processing
USPS Express Mail (for shipping overnight to PO Box ONLY)
$22.95 for Overnight Mail + $5 for Expedited processing
ONLY applications for birth certificates (NOT birth verifications) submitted by
mail need to be notarized
STATE OF ___________________________________
COUNTY OF _________________________________
This instrument was acknowledged before me on ___________________________
by _________________________________________________________________
(Date)
(Name of person acknowledging)
__________________________________
(Notary Public’s Signature)
(Personalized Seal)
Signature of Applicant
VS - 140 (9/18)
OFFICE USE ONLY
CASH
CHECK MONEY ORDER
REMIT No.
DATE
CREDIT CARD (walk in only)
AMOUNT$
FILED BY STAFF
Your relationship to Person named
on Certificate: Self / Parent
Other-Specify _______________________
TEXAS BIRTH CERTIFICATE APPLICATION
PLEASE PRINT. APPLICATION MUST BE ORIGINAL (INCLUDING SIGNATURE). NO CROSS OUT OR WHITE
OUT WILL BE ACCEPTED. INCLUDE A PHOTOCOPY OF YOUR VALID ID WHEN SENDING IN THE REQUEST.
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 O
ce of Early Childhood Coordination of
Health and Human Services.
I authorize mailing to the address below, if mailing to address other than listed above.
-
-
Parent 2: First Middle, Last name prior to first marriage (Maiden Name). Please separate with a space between first, middle and last name.
TEXAS ONLY
SEE INSTRUCTIONS ON BACK.
BIRTH CERTIFICATE NUMBER 142 -
DOCUMENT CONTROL NUMBER(S)
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 (If record is not found, the fees are not refundable and are kept. If record is not on file, VSS will issue a "not found" letter.)
Date Signed (MM/DD/YYYY) __ __ / __ __ / __ __ __ __
Step 4 : AFFIDAVIT
click to sign
signature
click to edit
click to sign
signature
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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
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, 1100 W.
49th St., Austin, TX 78756
Walk In: Same day service in most cases. Hours are Monday-Friday 8:00 am - 5:00 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 20-25 business days after receipt of the request.
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 photocopy of his or her valid photo ID issued by a governmental entity. See Section 181.28 of the
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)/).
Applications for birth certificates cannot be processed without a photo ID or alternate IDs and the signature of the applicant. If a
valid photo ID or alternate IDs and signatures are not received, the application will not processed.
TEXAS BIRTH CERTIFICATE APPLICATION
PLEASE PRINT. APPLICATION MUST BE ORIGINAL (INCLUDING SIGNATURE). NO CROSS OUT OR WHITE
OUT WILL BE ACCEPTED. INCLUDE A PHOTOCOPY OF YOUR VALID PHOTO ID WHEN SENDING
IN THE REQUEST.
Walk In Customer Checklist
Complete steps 1, 2, and 3 of the application. Please type or print clearly.
Sign and date the application
Have current driver's license, passport or state identification ready
Have appropriate fees ready. Make checks or money orders payable to DSHS - Vital Statistics.
Mail In / Expedited Customer Checklist
Complete steps 1, 2, and 3 of the application. Please type or print clearly.
Complete step 4 of the application: Sign and date the application in the presence of a notary public.
Enclose a copy of a current driver's license, passport or state identification.
Enclose appropriate fees. Make checks or money orders payable to DSHS - Vital Statistics.
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 certificate. 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 - H.B. No. 1260 Sec. 431.039. EXEMPTION FROM FEES FOR MILITARY PERSONNEL
BEING DEPLOYED. 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; SECTION 2. This Act takes effect September 1, 2007.
APPLICATIONS WITHOUT MILITARY ID AND MILITARY ORDERS WILL NOT BE PROCESSED.
For the status of your request, contact VSS by telephone at 1-888-963-7111 or by email at vrstatus@dshs.texas.gov.
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- TEXAS BIRTH CERTIFICATE APPLICATION (Grimes County)

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Completed 21 January 2021

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