San Joaquin County Public Health Services

Mail Application for Certified Copy of Birth Certificate

Effective July 1, 2003 California law permits only authorized individuals to receive authorized certified copies of birth records required to establish identity and related uses such as obtaining a driver’s license, passport, or insurance coverage. If you are requesting an authorized certified copy, complete all application sections and submit it with a notarized statement as described in section 4.

An informational certified copy may be obtained by any person but cannot be used to establish formal identity. If you are requesting an informational certified copy, complete sections 1 and 2 only and submit the application. A notarized statement is not required for an informational only copy.

The health department furnishes certified copies for births that were registered during the current and past calendar year only.

Submit this application form with the appropriate fees to:

Public Health Services – Vital Records Unit

PO Box 2009 Stockton, CA 95201-2009

Permanent records are kept at the County Recorder’s Office at:

6 S. El Dorado St. 2^nd floor

Stockton Ca. 95201

Certificate Type Requested: ___ Authorized Certified Copy ___Informational Only

Number of Certificates Requested ______

1. Newborn/Registrant Information

Name ___________________________________________ Birth Date___/___/___

Multiple Births – Additional Newborns (twins/triplets)

Name ___________________________________________

Name __________________________________________

Place of Birth _______________________ Mother’s Maiden Name_______________

2. Requestor Information

Name________________________________________

Mail Address___________________________ _______________ _____ ________

Number and Street City State Zip Code

3. Authorized Individual Information – Complete this section if requesting authorized certified copy. Specify which category of authorized individual you are:

A parent, legal guardian, grandparent, or sibling of the registrant.

A party entitled to receive the record as a result of a court order; an attorney or a licensed adoption agency seeking the birth record to comply with Section 3140 or 7603 of the Family Code.

A member of a law enforcement agency or representative of another governmental agency, as provided by law, who is conducting official business.

An attorney representing the registrant or registrant’s estate; a person or agency empowered by statute or appointed by a court to act on behalf of the registrant or his/her estate.

4. Notarized Statement – A written request for an authorized certified copy must be accompanied by a notarized statement sworn under penalty of perjury that the requester is an authorized person, as required by State law.Your application will be returned if the required statement below is not signed and notarized. This section is not required for an informational only copy.

Sworn Statement: I, _________________________, swear under penalty of perjury

Printed Name

under the laws of the State of California, that I am an authorized person to obtain an authorized certified copy of this/these birth records based on my relationship to the registrant(s) as specified in Section 3 of this application, in conformance with section 103526(c) of the California Health and Safety Code.

Sworn this ____ day of ________, 200__, at ______________, _____.

Day Month Year City State

________________________

Signature

Certificate of Acknowledgement

State of ________________________

County of _______________________

On ________________, before me personally appeared ___________________,

personally known to me, or

proved to me on the basis of satisfactory evidence,

to be the person whose name is subscribed to the above instrument and acknowledged to me that he/she executed the same in his/her authorized capacity, and that by his/her signature on the instrument the person, or the entity upon behalf of which the person acted, executed the instrument.

WITNESS my hand and official seal.

(NOTARY SEAL)

__________________________

Notary Signature

Fees – Fees for certificate copies are established by State law. Include a check or money order payable to San Joaquin County Public Health Services. The current fee is $14.00 per copy.