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Alpine County Recorder APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD $31.00 PER COPY PLEASE READ THE INSTRUCTIONS ON PAGE 2 BEFORE COMPLETING THE APPLICATION. CERTIFICATE TYPE: I am requesting an AUTHORIZED COPY (notarized sworn statement required) I am requesting an INFORMATIONAL COPY Part 1 - Relationship to Person on Certificate (Registrant): Check appropriate box. The registrant or a parent, legal guardian, child, grandparent, grandchild, sibling, spouse, or domestic partner of the registrant. (Legal guardian must provide documentation.) 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. Part 2 - Birth Record Information: Complete the information below as shown on the birth record. If requesting sealed record, contact California Department of Public Health Vital Records. FIRST Name MIDDLE Name LAST Name City of Birth (must be California) County of Birth Date of Birth - MM/DD/YYYY (or approximate date) Parent FIRST Name Parent LAST Name at Birth Parent FIRST Name Parent LAST Name at Birth Part 3 - Applicant Information: Please PRINT all information legibly. Applicant Name Mailing Address: Number, Street, and Unit # (if applicable) Zip Code City State/Province Country Telephone (include area code) Email Address Reason for Request Agency Use (if applicable) Agency Name Case/ID Number Contract Number Application Checklist: Check/Money Order Enclosed (No Cash) Notarized Sworn Statemen Enclosed (if applicable) t Number of Copies BIRTH VS 111 (2/24) Page 1 of 3 ---PAGE BREAK--- Alpine County Recorder INSTRUCTIONS 1. Complete a separate application for each birth record requested. 2. In Part 1, check the appropriate box according to the relationship to the person on the certificate. ONLY authorized individuals (Health and Safety Code Section 103526) listed in Part 1 may obtain an authorized copy. All others may receive a certified informational copy that will be marked, “Informational, Not a Valid Document to Establish Identity.” 3. If adopted and requesting current record, enter the adopted name in Part 2. To request the original birth certificate, provide a court order releasing the original sealed record and check the “Requesting sealed record” box. 4. Complete Part 2 and Part 3. In Part 2, provide as much information as possible to help identify the record. 5. Indicate the number of copies and submit $31.00 for each copy in the form of a check or money order, made payable to “Alpine County Recorder” in US dollars. DO NOT SEND CASH. 6. County Recorder will issue a Certificate of No Public Record (CNPR) if the record is not available and will retain the fee for the search, according to California law. 7. SWORN STATEMENT: • 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 attached sworn statement by signing and identifying their relationship to person listed on certificate. • Sworn statements must be notarized for authorized copy requests. Law enforcement and governmental agencies 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. 8. Mail completed applications with the fee(s) to the address below. VS 111 (2/24) BIRTH Page 2 of 3 Alpine County Recorder P.O. Box 155 or 99 Water St (overnight delivery) Markleeville, CA 96120 Phone (530) 694-2283 ---PAGE BREAK--- SWORN STATEMENT I, (Applicant’s Printed Name) Alpine County Recorder VS 111 (7/24) BIRTH Page 3 of 3 , 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 and am eligible to receive a certified copy of the birth, death, or marriage certificate of the following individual(s): Registrant (Name of person whose certificate you are requesting) Applicant's Relationship to Registrant (Must be an authorized person) (Day) (Month) (The remaining information must be completed in the presence of a Notary Public.) Subscribed to this day of , 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 (SIGNATURE OF NOTARY PUBLIC) WITNESS my hand and official seal. (SEAL) SIGN SIGN