Application For Certified Copies Of Birth Certificate - City Of Bedford
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1Receipt No. ________________
CITY OF BEDFORD
Cash
________________
APPLICATION FOR
VITAL STATISTICS
Check No.
________________
CERTIFIED COPIES OF
2000 FOREST RIDGE
Money Order ________________
BIRTH CERTIFICATE
BEDFORD, TX 76021-1895
MC/Visa ____________________
Expiration __________________
817-952-2112
PLEASE PRINT
817-952-2397 fax
Control No. _________________
*Abstracts will be issued if Bedford is not the Local Registrar. Abstracts
MAY NOT be accepted by the U.S. Passport Office as valid birth certificates.
THE FOLLOWING ARE THE ONLY
___ Abstract*
___ Full Record
RECOGNIZED QUALIFIED APPLICANTS
BIRTH
Please check your relationship to person in #1:
# REQUESTED
____ Self
____ Sibling
___1_ CERTIFIED COPY X $23.00
$23.00
____ Parent
____ Child
_____ EXTRA COPIES OF
____ Grandparent
____ Legal Representative
SAME RECORD X $23.00 ______
____ Stepparent
____ Guardian
_____ POLY SLEEVE X $2.00 ea.
______
____ Spouse
____ Military Recruiter
EXPEDITED SHIPPING
______
Via Express Mail
TOTAL ENCLOSED = ______
*I ACCEPT THIS CERTIFIED COPY AS IS:
State/Registrar File # ____________________
Full Name
1. First Name
Middle Name
Last Name at Birth
On Birth Record
2. Month
Date
Year
3. Sex
Date Of Birth
4. City or Town
County
State
City Of Birth
TEXAS
5. First Name
Middle Name
Last Name
Full Name Of Father
Full Maiden Name
6. First Name
Middle Name
Maiden Name
Of Mother
8. YOUR NAME: _________________________________________
9.
8:00am – 5:00pm
(_____)_________________
Phone#
10. MAILING ADDRESS: ________________________________________________________________________________
STREET ADDRESS
CITY
STATE
ZIP
11. YOUR RELATIONSHIP TO PERSON IN ITEM 1: __________________________________________________________
12. PURPOSE FOR OBTAINING THIS RECORD: ____________________________________________________________
WARNING: THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT IN THIS FORM CAN BE 2-10
YEARS IN PRISON AND A FINE OF UP TO $10,000. {HEALTH AND SAFETY CODE, CHAPTER 195, SEC. 195.003}
____________________________________
____________________________
SIGNATURE OF APPLICANT
DATE
IDENTIFICATION TYPE ________________________
NUMBER _________________________
Driver’s License, I.D. Card, etc
on Driver’s License, I.D. Card, etc.
.
Birth records are confidential for 75 years: therefore, issuance is restricted to qualified applicants. PLEASE ATTACH A PHOTOCOPY OF
IDENTIFICATION TO APPLICATION.
WE WILL PROCESS NO REQUEST WITHOUT IDENTIFICATION. Administrative rules require that on restricted
records, all identifying information (items 1-6), relationship (item 11), and purpose (item 12) be provided in order to issue the record.
Fees are subject to change without notice. (Call 817-952-2112 for fee verification.)
Office Use Only
Issued by:
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