Application For Birth Certificate Form - Sutter County Clerk-Recorder
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2Sutter County Clerk-Recorder
Donna M. Johnston, County Clerk-Recorder-Registrar of Voters
433 Second Street
Yuba City, CA 95991
Phone: (530) 822-7134
Fax: (530) 822-7214
APPLICATION FOR BIRTH CERTIFICATE
California Health & Safety Code, Section 103526, permits only authorized persons as defined below to receive Authorized Certified
Copies of Vital Records. Those who are not authorized by law to receive an Authorized Certified Copy will receive an Informational
Certified Copy marked “INFORMATIONAL, NOT VALID DOCUMENT TO ESTABLISH IDENTITY.”
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Authorized Certified Copy or
Informational Certified Copy
Please indicate whether you would like an:
Birth Certificate Information:
Last Name: _______________________ First Name: _____________________ Middle: _____________
Date of Birth (Month-Day-Year): ______-_______-________ Number of Copies ($25 each): _________
Applicant Information (Person Making Request):
Name of Applicant: __________________________
Telephone Number ______-_______-_________
Mailing Address: _____________________________ City: ___________ State: ____ Zip Code: ______
Signature of Applicant: ______________________________________________
Date: ___________
Who are you - Relationship of Applicant to Registrant on Certificate (Mark One):
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Registrant
Parent/Legal Guardian
Grandparent/Grandchild
Child
(Name on Certificate)
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Law Enforcement/Govt Agency
Licensed Adoption Agency
Spouse/Domestic Partner
Sibling
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Agent/Employee Funeral Establish.
Attorney of Record
Authorized by Court Order
I, ___________________________________ swear (or affirm) under penalty of perjury under the laws of the State of
California, that I am an authorized person, as defined in California Health & Safety Code Section 103526 (c), and eligible
to receive an Authorized Certified copy of the vital record identified on this application form.
Sworn this ____ day of ____________________, 20____, at _______________________________________________
City and State
Signature:_____________________________________
For Requests By Mail For Authorized Certified Copy-The following must be completed by a Notary Public.
Notary Acknowledgement
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.
State of _____________________) ss.
County of ___________________)
On ___________ before me, __________________________, a Notary Public, personally appeared ___________________________
who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within 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.
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.
Signature of Notary: _________________________________
(seal)
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