Application For Certified Copy Of Birth Record Form - Modoc County (Page 2 of 3) in pdf

As of July 1, 2003, ONLY individuals who are authorized by Health and Safety Code Section 103526 can obtain a Certified

Copy of a Birth Record to establish identity of the registrant (person listed on the certificate). (Page 1 identified the individuals

who are authorized to make the request.) All others may receive a Certified Informational Copy which will be marked

"Informational, Not a Valid Document to Establish Identity"

Confidential Information on Birth Record: Some Individuals have special needs for a birth certificate that contains the

confidential information provided at the time the birth record was prepared. This confidential information may be used to

establish ethnicity, to provide health background, or for other personal reasons. For information on how to obtain a birth

certificate containing the confidential information, please refer to the Birth a Certificate section of the California Department

Of Public Health at

(then select "Services"). Only Specific individuals may obtain confidential copies

Complete a separate application for each birth record requested.

Complete the Application Information section on Page 1 and provide your signature where indicated. In the Birth

Certificate Information section, provide all the information you have available to identify the birth record. If the Information

you furnish is incomplete or inaccurate, we may not be able to locate the record.

If the registrant has been adopted, make the request in the adopted name. (If you're requesting a copy of the original

birth certificate, you must provide a court order releasing the original sealed record the to Department of Public Health.

the local registrant of births does not have the sealed certificate).

SWORN STATEMENT:

The authorized individual requesting the certified copy must sign the attached Sworn Statement, declaring under penalty

of perjury that they are eligible to receive the certified copy of the birth record, and identify their relationship to the registrant

the relationship must be one of those identified on Page 1.

If the application is being submitted by mail, the Sworn Statement must be notarized by a Notary Public.

(To find a Notary Public, see your local yellow pages or call your banking institution.) Law enforcement and local state

government agencies are exempt from the notary requirement.

You do not have to provide a Sworn Statement if you are requesting a Certified Informational Copy of the birth record.

Submit $25.00 for each copy requested. If no birth record id found, the $25.00 fee will be retained for searching the record

(as required by law) and a "Certificate of No Public Record" will be issued to the applicant. Indicate the number of copies

you want and include the correct fee(s) in the form of a personal check or postal or bank money order made payable to

The Modoc County Recorders Office. Mail this application with the fee(s) to the Modoc County Recorders Office at the

address below.

Returning Completed Certificates: Completed certificates are returned using the U.S. Postal Services.

Modoc County Recorders Office

204 S. Court Street. Rm 106.

Alturas, CA 96101

BIRTH

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VS 111 Rev. (11/10)

Application For Certified Copy Of Birth Record Form - Modoc County Page 2