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APPLICATION FOR CERTIFIED COPY OF MARRIAGE RECORD DO NOT Complete This Application Before Reading the Instructions on Page 3 I would like a Certified Copy. This copy will establish the identity of the registrant. (To receive a Certified Copy you MUST INDICATE YOUR RELATIONSHIP TO THE REGISTRANT (select from the list below) AND COMPLETE THE ATTACHED SWORN STATEMENT declaring that you are eligible to receive the Certified Copy. The Sworn Statement MUST BE NOTARIZED if the application is submitted by mail unless you are a law enforcement or local or state governmental agency.) Fee: $15 per copy for Marriage Record - I would like a Certified Informational Copy. This document will be printed with a legend on the face of the document that states, “INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY.” (A Sworn Statement does not need to be provided.) NOTE: Both documents are certified copies of the original document on file with our office. With the exception of the legend, the documents contain the exact same information. To receive a Certified Copy I am: The registrant (person listed on the certificate) or a parent or legal guardian of the registrant (legal guardians should provide documentation). A party entitled to receive the record as a result of a court order (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.) A child, grandparent, grandchild, brother or sister, spouse, or domestic partner of the registrant. An attorney representing the registrant or the registrant’s estate, or any person or agency empowered by statute or appointed by a court to act on behalf of the registrant or the registrant’s estate. (If you are requesting a Certified Copy under a power of attorney, please include a copy of the power of attorney with this application form.) PLEASE TYPE OR PRINT THE INFORMATION REQUESTED BELOW EXCEPT WHERE SIGNATURE IS REQUIRED APPLICANT INFORMATION – You MUST Complete This Section (PLEASE PRINT OR TYPE) Purpose for Which Certified Copy is to Be Used Today’s Date Area Code and Telephone Name of Person Completing Application Signature of Person Requesting Record(s) Mailing Address – Number, Street City State ZIP Code Name of Person Receiving Copies, if Different From Above Number of Copies Amount Enclosed Purpose of Request Mailing Address for Copies, if Different From Above City State ZIP Code MARRIAGE CERTIFICATE: Complete First and Second Person Information Name of First Person – First Name Middle Name Current Last Name Birth Last Name Date of Birth Place of Birth Name of Father/Parent of First Person Name of Second Person – First Name Middle Name Current Last Name Birth Last Name Date of Birth Place of Birth Name of Father/Parent of Second Person Date of Marriage – Month, Day, Year If Date Unknown, Enter Year(s) to be Searched County That Issued License County of Marriage MARRIAGE Page 1 of 3 ---PAGE BREAK--- SWORN STATEMENT I, declare under penalty of perjury under the laws of the State of California, (Applicant’s Printed Name) 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 Office of Vital Records staff.) Subscribed to this day of at (Day) (Month) (City) (State) (Applicant’s Signature) Note: If submitting your order by mail, you must have your Sworn Statement notarized using the Certificate of Acknowledgment below. The Certificate of Acknowledgement must be completed by a Notary Public. (Law enforcement and local and state governmental agencies are exempt from the notary requirement.) 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. CERTIFICATE OF ACKNOWLEDGMENT State of County of On 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 MARRIAGE Page 2 of 3 ---PAGE BREAK--- INSTRUCTIONS: 1. Use a separate application for each different record that you are requesting. Include $15 for each marriage record. If we cannot locate the record based on the information you provide, state law requires that we keep the fee (for our searching efforts), but we will provide you with a “Certificate of No Public Record.” 2. Provide as much information as possible to help us locate the specific record you are requesting. Complete First and Second Person Information for marriage requests. If the information you provide is incomplete or inaccurate, we may not be able to locate the record. 3. Identify the number of copies you want. Include a check or money order (for out-of-country requests, use an international money order payable in U.S. dollars) made payable to the ALPINE COUNTY RECORDER. Mail this application with the fee(s) and a self-addressed stamped envelope, to the Alpine County Recorder’s Office at the address below. 4. 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 marriage record, and identify their relationship to the registrant(s) – their relationship must be one of those identified on Page 1. • 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. • You do not have to provide a Sworn Statement if you request a “Certified Informational Copy” of the marriage record. 5. Returning Completed Certificates: Completed certificates are returned using the U.S. Postal Service. Mail this application with the fee(s) and a self-addressed stamped envelope to: Alpine County Recorder P.O. Box 155 Markleeville, CA 96120 (530) 694-2283 MARRIAGE Page 3 of 3