Fillable VITAL REGISTRAR APPLICATION FOR BIRTH OR DEATH CERTIFICATE (City of Temple, Texas)

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VITAL REGISTRAR APPLICATION FOR BIRTH OR DEATH CERTIFICATE (City of Temple, Texas)

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The VITAL REGISTRAR APPLICATION FOR BIRTH OR DEATH CERTIFICATE (City of Temple, Texas) form is 2 pages long and contains:

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U.S.A. forms for City of Temple, Texas

BROWSE CITY OF TEMPLE, TEXAS (TX) FORMS

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2 North Main St. – Room 103 (254) 298-5700
P.O. Box 207 Fax (254) 298-5637
Temple, Texas 76503 CitySecretary@templetx.gov
Vital Registrar – City of Temple
Application for Birth or Death Certificate
REQUESTORS: PLEASE PRINT; INCLUDE A PHOTOCOPY OF YOUR VALID PHOTO ID AND SWORN STATEMENT WHEN SENDING THE REQUEST.
WARNING…IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY MAKING A FASLE STATEMENT ON
THIS FORM OR SIGNING A FORM WHICH CONTAINS A FALSE STATEMENT IS 2 TO TEN YEARS IMPRISONMENT AND A FINE UP TO $10,000. (HEALTH
& SAFETY CODE, CHAPTER 195, SEC. 195.003)
BIRTH CERTIFICATES DEATH CERTIFICATES
_____CERTIFIED COPIES X $23.00______ _____CERTIFIED COPIES X $21.00______
_____ADDT’L COPIES X $4.00______
BIRTH/DEATH RECORD INFORMATION…PLEASE PRINT
1.Full Name of Person on
Record
First Name Middle Name Last Name
2.Date of Birth or Death Month Day Year 4. Sex
3.Place of Birth or Death City or Town County State
5.Full Name of Parent 1 First Name Middle Name Last Name/Maiden Name
6.Full Name of Parent 2 First Name Middle Name Last Name/Maiden Name
Social Security No. of Deceased Birth Date of Deceased Birth Place of Deceased
REQUESTOR INFORMATION
Requestor Name Telephone # E-mail Address
Full Mailing Address Street Address City State Zip
Relationship to person listed above Purpose for obtaining this record (please note if for passport)
SIGNATURE OF APPLICANT ____________________________________ DATE _____________________
***Documents are mailed via regular U.S. Mail. This office is NOT responsible for misdirected mail***
CHECKS PAYABLE TO CITY OF TEMPLE…… ALL SALES ARE FINAL
A COPY OF THE APPLICANT’S PHOTO ID IS REQUIRED FOR PROCESSING
Birth Certificate ID Requirements in Texas Brochure
Requisitos de identificación para las actas de nacimiento en Texas Brochure
If paying by Credit Card (MASTERCARD, VISA & DISCOVER), provide information below, including billing address for
Credit Card holder. Also include ID of Credit card holder if different than purchaser.
OFFICE USE ONLY
Receipt No.___________ Form No. ______________ File No. ______________Emp. I.D. _______________
Revised 12/2018
Page 1 of 2
CARDHOLDER NAME
ACCOUNT NUMBER & VERIFICATION NO. (3-digit
code on back of card in signature area)
EXPIRATION DATE
VITAL REGISTRAR
APPLICATION FOR BIRTH OR DEATH CERTIFICATE
2 NORTH MAIN ST., SUITE 103, P.O. BOX 207, TEMPLE, TX 76503
254.298.5700 • FAX: 254.298.5637 • CITYSECRETARY@TEMPLETX.GOV
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NOTARIZED PROOF OF IDENTIFICATION
PART I. ENTER NAME, DATE AND PLACE OF BIRTH/DEATH, AND NAMES OF PARENTS AS INFORMATION
APPEARS ON BIRTH/DEATH CERTIFICATE
FULL NAME OF PERSON ON RECORD DATE OF BIRTH/DEATH
PLACE OF BIRTH/DEATH (CITY OR COUNTY) SEX
FULL NAME OF PARENT 1 FULL NAME OF PARENT 2
PART II. ENTER RELATIONSHIP TO PERSON ON RECORD AND THE TYPE OF ID USED
NAME AND RELATIONSHIP TO PERSON ON RECORD TYPE AND NUMBER OF ID USED WHEN NORTARIZED
AFFIDAVIT OF PERSONAL KNOWLEDGE
PART III. THIS SECTION MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC
STATE OF ________________________
COUNTY OF ______________________
Before me on this day appeared _________________________________________________________________
(name)
Now residing at ______________________________________________________________________________
(Address) (City) (State) (Zip)
who is related to the person names in Part I as ______________________________ and who on oath deposes and
(Relationship)
says that the contents of this affidavit are true and correct.
Applicant’s Signature _______________________________
Sworn to and subscribed before me, this __________ day ________________________, 20 ______.
SIGNATURE OF NOTARY
COMMISSION EXPIRES
(SEAL)
TYPED OR PRINTED NAME
STREET ADDRESS
CITY, STATE, ZIP
WARNING…IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY MAKING
A FASLE STATEMENT ON THIS FORM OR SIGNING A FORM WHICH CONTAINS A FALSE STATEMENT IS 2 TO TEN
YEARS IMPRISONMENT AND A FINE UP TO $10,000. (HEALTH & SAFETY CODE, CHAPTER 195, SEC. 195.003)
MAIL THIS SWORN STATEMENT, APPLICATION, PAYMENT, & PHOTOCOPY OF YOUR VALID PHOTO ID TO:
City Secretary’s Office
Attn: Vital Records
P.O. Box 207
Temple, Texas 76503
(APPLICATIONS WITHOUT SIGNATURE, SWORN STATEMENT & PHOTO ID WILL NOT BE PROCESSED)
Revised 12/2018
Page 2 of 2
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VITAL REGISTRAR APPLICATION FOR BIRTH OR DEATH CERTIFICATE (City of Temple, Texas)

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Completed 16 July 2020

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