Application For Certified Copy Of Birth Record Form - Modoc County
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3Modoc County Recorders Office
APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD
DO NOT Complete This Application Before Reading the Instructions on Page 2
In an attempt to stop the illegal use of vital records, as and part of statewide efforts to reduce identity theft, a new law (effective July 1, 2003)
changed the way certified copied of birth certificates are issued. Certified Copies to establish the identity of a registrant can be issued only to
authorized individuals, as indicated below. All others will be issued Certified Informational Copies that are not valid to establish identity
Fee: $25.00 per copy (payable to the Modoc County Recorders Office)
Please indicate the type of certified copy you are requesting:
I would like a Certified copy. This Copy will establish the identity
of the registrant. (To receive a Certified Copy you MUST
I would like a Certified Informational Copy. This
INDICATE YOUR RELATIONSHIP TO THE REGISTRANT by
document will be printed with a legend on the face of
selection from the list below AND COMPLETE THE ATTACHED
the document that states "INFORMATIONAL, NOT
SWORN STATEMENT declaring that you are eligible to receive the
A VALID DOCUMENT TO ESTABLISH IDENTITY"
Certified Copy. The Sworn Statement MUST BE NOTARIZED if
the application is submitted by mail unless you are a law
(A Sworn Statement does not need to be provided)
enforcement or local or state government agency)
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
The registrant (person listed on the 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 requirements of Section 3140 or 7603 of the Family code
A member of law enforcement agency or a representative of another government 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.)
APPLICANT INFORMATION (PLEASE PRINT OR TYPE)
Today's Date:______________________
Agency Name (If appropriate)
Agency Case No.(If appropriate)
Purpose of Request
Printed Name of Applicant
Number of copies
Amount Enclosed
Mailing Address-Number, Street
Name of Person receiving Copies, if different from Applicant
City
State
Zip Code
Mailing Address for Copies, If Different from Applicant
City
State, & Zip Code
Daytime Telephone (include Area Code)
(
)
Adopted: No
Yes
(If yes, see # 4 on page 2)
BIRTH CERTIFICATE INFORMATION (PLEASE PRINT OR TYPE)
FIRST Name of Certificate
MIDDLE Name of Certificate
BIRTH LAST Name on Certificate
City of Birth (Must be in California)
County of Birth
Sex
Date of Birth-MM/DD.CCYY (if unknown, enter approximate date of birth)
Female
Male
BIRTH LAST Name on certificate-Father/Parent
FIRST Name on Certificate-Father/Parent MIDDLE Name on Certificate
BIRTH LAST Name on Certificate-Mother/Parent
FIRST Name on Certificate-Mother/Parent MIDDLE Name on Certificate
BIRTH
VS 111 Rev. (11/10)
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