Fillable Vital Records Request Form

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Vital Records Request Form

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The Vital Records Request Form form is 2 pages long and contains:

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  • 4 check-boxes
  • 45 other fields

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Hugh Nguyen
Orange County Clerk-Recorder
P.O. Box 238, Santa Ana, CA 92702
County Administration South
601 N. Ross Street, Santa Ana, CA 92701
Vital Records Request Form
(For Mail Use Only – Mail your request to address above)
• Please make your check or money order payable to the Orange County Clerk-Recorder (no cash)
• Only an authorized person can receive an official certified copy.
(see second page for authorized persons list)
• If you are not an authorized person, you will receive a redacted copy with the following stamped on it,
“Informational Not a Valid Document to Establish Identity”
Please Print or Type Clearly – Use Black Ink Only
Birth/Death/Single Status Certificate Information (We only maintain records for births and deaths that occurred in Orange County)
Complete this section if requesting a birth/death/single status certificate.
For births or deaths that occurred within the past 60 days, please call the County Health Care Agency at (714) 480-6700.
A “Certificate of No Record” will be sent if we cannot locate the record you are requesting.
For adoptions go to www.dhs.ca.gov
Birth Certificate $32/copy Death Certificate $24/copy Single Status Certificate $17/copy Number of Copies_____
_________________________ __________________________ __________________________
First Name(s) Middle Name(s) Last Name(s)
_________________________ __________________________ _________
_________________
City of Birth/Death Date of Event/Occurrence Mother’s Maiden Name (birth records only)
Check one: Certified copy Informational Copy Military/Veterans benefits (attach letter from VA)
Marriage Certificate Information (We only maintain records for marriage licenses that were issued by the Orange County Clerk-Recorder)
Complete this section if requesting a marriage certificate.
A “Certificate of No Record” will be sent if we cannot locate the record you are requesting.
Marriage Certificate $17/copy Number of Copies _________
Date of Marriage:_______________
_________________________ __________________________ __________________________
First Name(s) 1
st
Person Middle Name(s) 1
st
Person Last Name(s) 1
st
Person
(maiden name if applicable)
_________________________ __________________________ __________________________
First Name(s) 2
nd
Person Middle Name(s) 2
nd
Person Last Name(s) 2
nd
Person
(maiden name if applicable)
Check one: Certified copy Informational Copy Military/Veterans benefits (attach letter from VA)
Requestor’s Information:
Your Name: _____________________________________ Relationship to person(s) on certificate(s):____________________
Mail Copi
es to: _________________________________________________________________________________________
Address and apt. # if needed City State Zip Code
Dayti
me phone#: ____________________________ Reason for copy:_________________________
I agree not to use the above reference record obtained from this application or any portion thereof, for fraudulent purposes.
I certify/declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Signature________________________________ Date:______________________
The penalty of perjury statement on the next page must be signed before a notary public
For office use only:
Reviewed by:___________ Date: ________ # of copies: ______ Payment amount: $________ Exempt Military/Veteran
Check # __________ Cash:_____ Money order # _______________ Processed by: _________ Date Processed:________
Rev 11/21
Check one:
You should know:
• Use a separate application form for each record you request.
• One notarized sworn statement is required for copies. The sworn statement below must show the name of each person on the
certificate and your relationship to them.
• Notarization is not required for informational copies.
• To receive an official certified copy of this record you must be:
o On the certificate or be a parent, legal guardian/custodian, child, grandparent, grandchild, sibling, spouse/registered domestic
partner, attorney for the individual/estate or representative of an adoption agency.
o A funeral director ordering copies of a death certificate on behalf of an individual specified in paragraph (1) to (8), inclusive of
subdivision (a) of Section 7100 of Health and Safety Code.
o Applicable to death certificate orders only: Surviving Next of Kin as authorized under the California Health and Safety Code
Section 7100.
Sworn Statement
I, ______________________________, declare under penalty of perjury under the laws of the State of California, I am an authorized person,
(Type/Print your name)
as defined in California Health and Safety Code Section 103526(c), and am eligible to receive a certified copy of the birth, marriage, or death
record for the following:
Name on certificate(s)
Your relationship to the person on the certificate
Subscribed to this ________day of ________________, 20_____ at ___________________________________
(Day) (Month) (Year) (City and State)
___________________________________________
Signature (You must sign before a Notary Public)
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, ____________________________________________, 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 c
ertify under PENALTY OF PERJURY under the laws of the State of California that the forgoing paragraph is true and correct.
WITNESS my hand and official seal
__________
___________________________
(Notary Signature) (Seal)
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Vital Records Request Form

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Completed 7 February 2022

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