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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)
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
Reviewed by:___________ Date: ________ # of copies: ______ Payment amount: $________ Exempt Military/Veteran
Check # __________ Cash:_____ Money order # _______________ Processed by: _________ Date Processed:________
Rev 11/21