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

Application For Certified Copy Of Birth Record Form - Modoc County Page 3

SWORN STATEMENT

I, ______________________________, declare under penalty of perjury under the laws of the State of California.

(Applicant's Printed Name)

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)

Name of Person Listed on Certificate

Applicant's Relationship to Person Listed on Certificate

(Must be a Relationship Listed on Page 1 of Application)

(The remaining information must be completed in the presence of a Notary Public or Recorders Office Staff)

Subscribed to this_______day of ________, 20___at ______________, _________________,

(Day)

(Month)

(City)

(State)

___________________________________________________________

(Applicant's Signature)

Note: If submitting your order by mail, you must have your Sworn Statement notarized using the Certificate of

Acknowledgement below. The Certificate of Acknowledgment must be completed by a Notary Public.

(Law enforcement and local and state governmental agencies are exempt from the notary requirement.)

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

CERTIFICATE OF ACKNOWLEDGMENT

State of ______________________)

County of _____________________)

On________________ before me, ________________________________, Personally appeared__________________________,

(here insert name and title of the officer)

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 by

his/her/their signature(s) on the instrument the person(s), or 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 is true and correct.

Witness my hand and official deal.

(SEAL)

___________________________________________________

SIGNATURE

Page 3 of 3

VS 111 Rev. (11/10)

Application For Certified Copy Of Birth Record Form - Modoc County Page 3