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Alpine County Recorder APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD PLEASE READ THE INSTRUCTIONS ON PAGE 3 BEFORE COMPLETING THIS APPLICATION California law (Health and Safety Code Section 103526), permits only authorized Individuals as listed on the application to receive certified copies of birth records. Those who are not authorized by law to receive an authorized certified copy will receive a certified Informational copy with the legend, "INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY." Please Indicate the type of certified copy you are requesting: I am requesting a Certified AUTHORIZED copy I am requesting a Certified INFORMATIONAL copy NOTE: Both documents are certified copies of the original document on file with Alpine County Recorder - Vital Records With the exception of the legend and redaction of signatures and Social Security Number, the documents contain the same information. To receive an AUTHORIZED copy, you MUST INDICATE YOUR RELATIONSHIP TO THE REGISTRANT below. To receive a certified copy, the applicant must sign a sworn statement that he or she is authorized to receive the certified copy. The Sworn Statement MUST BE NOTARIZED unless you are a member of a law enforcement agency or a representative of a state or local government agency. RELATIONSHIP: Registrant (Name on Certificate) Child/Sibling of Registrant Grandparent/Grandchild of Registrant Spouse/Registered Domestic Partner of Registrant Authorized by Court Order (Include copy of the court order.) Attorney Representing Registrant or Registrant's Estate Law Enforcement/Govt. Agency (conducting Official Business) Attorney/Licensed Adoption Agency {Under CA Family Code§ 3140 or7603) Parent/Legal Guardian of Registrant (Legal guardian must provide documentation.) Power of Attorney/Executor of the Registrant's Estate (Include a copy of the power of attorney or supporting documentation identifying you as executor.) APPLICANT INFORMATION {PRINT OR TYPE) Today's Date: / / 20 Agency Name (if applicable) Agency Case Number Inmate ID Number Name of Person Completing Application Signature of Applicant Purpose of Request Check this box for CNPR Request Mailing Address - Number, Street, and Unit# (If applicable) Amount Enclosed - DO NOT SENDCASH Check Money Order Number of Copies City Name of Person Receiving Copies if Different from Applicant State/Province I ZIP Code Country Mailing Address for Copies if Different from Applicant Daytime Telephone Number Email Address ( ) City State ZIP Code BIRTH RECORD INFORMATION {PRINT OR TYPE) Adopted: No Yes (If Yes, see #4 on Page 3) Complete the Information below as shown on the birth record, to the best of your knowledge. FIRST Name MIDDLE Name LAST Name City of Birth (must be In California) County of Birth Date of Birth - MM/DD/YYYY (If unknown, enter approximate date) FIRST Name Mother Father Parent MIDDLE LAST (Birth/Before Marriage/Domestic Partnership) FIRST Name Mother Father Parent MIDDLE LAST (Birth/Before Marriage/Domestic Partnership) BIRTH Page 1 of 3 FEE: $29 PER COPY (PAYABLE TO ALPINE COUNTY RECORDER Check / Money Order Enclosed Submit Check or Money Order – Do Not Send Cash Notarized Sworn Statement Enclosed (if applicable) ---PAGE BREAK--- vs 111 (06/19) Alpine County Recorder SWORN STATEMENT I, , 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): Name of Person Listed on Certificate Applicant's Relationship to Person Listed on Certificate (Must Be a Relationship Listed on Page 1 of Application) (The remaining information must be completed in the presence of a Notary Public or Alpine County Recorder’s staff.) Subscribed to this day of , 20 , at, (Day) (Month) (City) (State) (Applicant's Signature) Note: If submitting your order by mall, you must have your Sworn Statement notarized using the Certificate of Acknowledgment below. The Certificate of Acknowledgment must be completed by a Notary Public. (Law enforcement and local and state governmental agencies are exempt from the notary requirement.) Only one sworn statement is required for multiple records. CERTIFICATE OF ACKNOWLEDGMENT State of ) County of ) On before me, personally appeared , (Insert name and title of the officer) 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 WITNESS my hand and official seal. (SEAL) SIGNATURE OF NOTARY PUBLIC BIRTH Page 2 of 3 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. ---PAGE BREAK--- vs 111 (06/19) Alpine County Recorder INFORMATION: Birth records have been maintained by the California Department of Public Health-Vital Records (CDPH-VR) since July 1, 1905, The name required on Vital Records (see Items 1C, 6C, 7C, 9C, and 12C) Is the name given at birth, or a name received through adoption, court-ordered name change, or naturalization, AKAs (Also Known As) and assumed names cannot be entered as the legal name on the birth record, INSTRUCTIONS: 1. ONLY Individuals who are authorized by Health and Safety Code Section 103526 can obtain a Certified Copy of a birth record to establish identity of the registrant (person listed on the certificate), Page 1 identifies the individuals who are authorized to make the request. All others will receive a Certified Informational Copy which will be marked, "Informational, Not a Valid Document to Establish Identity." Confidential Information on Birth Record: Some individuals have special needs for a birth certificate, that contains the confidential information provided at the time the birth record was prepared. This confidential information may be used to establish ethnicity, to provide health background, or for other personal reasons. For information on how to obtain a birth certificate containing the confidential information, please refer to the Birth Record section of the CDPH-VR website at: www.cdph.ca.gov. Only specific individuals may obtain confidential copies. 2. Complete a separate application for each different birth record requested. 3. Complete the Applicant Information section on Page 1 and provide your signature where indicated, In the Birth Record information section, provide all the information you have available to identify the birth record. If the information you furnish is incomplete or inaccurate, we may not be able to locate the record. 4. If the registrant has been adopted, make the request in the adopted name. If you are requesting a copy of the origin al birth certificate, you must provide a court order releasing the original sealed record, 5. If you require documentation that a birth record does not exist, check the box for CNPR (Certificate of No Public Record) request on the application. 6. SWORN STATEMENT: • The authorized individual requesting the certified copy must sign the attached Sworn Statement, declaring under penalty of perjury that they are eligible to receive the certified copy of the birth record and identify their relationship to the registrant - the relationship must be one that is identified on Page 1. Only one sworn statement is required for multiple records. • If the application is being submitted by mail, the Sworn Statement must be notarized by a Notary Public. To find a Notary Public, see your local yellow pages or call your banking Institution. Law enforcement and local and state governmental agencies are exempt from the notary requirement. • A Sworn Statement notarized by a foreign notary must have an apostille attached. An Apostille is a certificate that authenticates a document for use in another country. Foreign notarizations obtained from 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 country do not require an apostille. • You do not have to provide a Sworn Statement if you are requesting a Certified Informational Copy of the birth record. Submit $29 for each copy requested. If no birth record is found, the fee will be retained for searching for the record (as required by law) and a "Certificate of No Public Record" will be issued to the applicant. Indicate the number of copies you want and include the correct fee(s) in the form of a personal check or postal or bank money order (International Money Order for out-of-country requests) made payable to Alpine County Recorder. Mail this application with the fee(s) and a return postage paid self-addressed envelope to the Alpine County Recorder at the address below. Mail completed applications with the fee(s) to: Alpine County Recorder P.O. Box 155 or 99 Water St (overnight delivery) Markleeville, CA 96120 Phone# (530) 694-2283 BIRTH Page 3 of 3