County Of San Diego
COUNTY OF SAN DIEGO
ASSESSOR/RECORDER/COUNTYCLERK
APPLICATION FOR BIRTH CERTIFICATE BY MAIL
$17.00 FEE FOR BIRTH CERTIFICATE OR LETTER OF NO RECORD
NON-REFUNDABLE
Effective July 1, 2003, California State Law, Health and Safety Code, Section 103526, permits only authorized persons as defined
below to receive certified copies of birth records.
Those who are not authorized by law to receive a certified copy will receive a
certified
copy
marked
"INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY."
Please
indicate
below whether you would like a Certified Copy or a certified Informational Copy.
I would like a Certified copy of the record identified on the
I would like a certified Informational Copy of the record
application form.(In order to receive a Certified Copy, you
identified on the application form.(You are not required
must indicate your relationship to the person named on the
to select from the list below or complete the statement of
application form by selecting from the list below.)
identity in order to receive an Informational Copy.)
I am:
The registrant (person named on certificate) or a parent or legal guardian of the registrant.
A party entitled to receive the record as a result of a court order, or an attorney or a licensed adoption agency
seeking the birth record in order to comply with the requirement of Section 3140 or 7603 of the Family Code.
A member of a law enforcement agency or a representative of another governmental agency, as provided by law,
who is conducting official business.
A child, grandparent, grandchild, sibling, 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.
BIRTH INFORMATION (PLEASE PRINT OR TYPE) - $17.00 for each certified copy
Name on Certificate - First Name
Middle Name
Last Name
Date of Birth
County of Birth
Mother's Full Maiden Name
No. of Copies
BIRTH INFORMATION (PLEASE PRINT OR TYPE) - $17.00 for each certified copy
Name on Certificate - First Name
Middle Name
Last Name
Date of Birth
County of Birth
Mother's Full Maiden Name
No. of Copies
BIRTH INFORMATION (PLEASE PRINT OR TYPE) - $17.00 for each certified copy
Name on Certificate - First Name
Middle Name
Last Name
Date of Birth
County of Birth
Mother's Full Maiden Name
No. of Copies
BIRTH INFORMATION (PLEASE PRINT OR TYPE) - $17.00 for each certified copy
Name on Certificate - First Name
Middle Name
Last Name
Date of Birth
County of Birth
Mother's Full Maiden Name
No. of Copies
Note: The Statement of Identity must accompany this request in our office before a certificate can be issued.
Requestor's Name: ___________________________________________________________________________________________
PLEASE PRINT
Vitals Form #V4A (01/2009)
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STATEMENT OF IDENTITY
I, _____________________________________________, swear under penalty of perjury under the laws of the State of
(Print Name)
California, that I am an authorized person, as defined in California Health and Safety Code Section 103526(c), and am eligible to
receive a certified copy of the birth or death record of the following individual(s):
Relationship to Person Listed on
Name of Person Listed on Certificate
Type
No. of Copies
Certificate
Birth
Death
Birth
Death
Birth
Death
Birth
Death
Sworn this _______ day of ____________, 20______, at_________________________________, _______________.
(Day) (Month) (City) (State)
_______________________________________________________
(Signature)
Note: If submitting your order by mail and requesting a Certified Copy (not an Informational Copy), you must have your sworn
statement notarized using the Certificate of Acknowledgement below. The notary is only verifying the identity of the person requesting
the copy not the relationship to the registrant.
Only one notarization is required even though the requester may have a different authorized relationship to each record being
requested, (i.e. Mother on one request, Registrant on another request, etc.).
CERTIFICATE OF ACKNOWLEDGEMENT
State of _________________________
County of _______________________
On ____________________, before me, __________________________________________________________, Notary Public,
(name 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 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.
______________________________________________________
NOTARY SIGNATURE
Mail Certificate to:
Name _______________________________________________
Address _____________________________________________
Please mail this request along with your payment (check or
City, State, Zip _______________________________________
money order payable to SD County Recorder ) to:
Email _______________________________________________
San Diego Recorder/County Clerk
Phone (______) _______________________________________
P.O. Box 121750
San Diego, Ca 92112-1750
Number of Birth _____________ x $17.00 = ________________
Number of Death ____________ x $12.00 = ________________
TOTAL = ________________
Vitals Form #V3B/4B (01/2009)
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