Form Ccr Vital 01 - Application For Certified Copy Of Birth Record

MARK A. LUNN

VENTURA COUNTY CLERK AND RECORDER

APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD

In an attempt to stop the illegal use of vital records, and as part of statewide efforts to reduce identity theft, a new law (effective July 1, 2003)

changed the way certified copies 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.

Fees: $20 per copy (payable to the Ventura County Clerk and Recorder).

Please indicate the type of certified copy you are requesting:



I would like a Certified Copy. This copy will establish the identity

I would like a Certified Informational Copy. This

of the registrant. (To receive a Certified Copy you must indicate

document will be printed with a legend on the face of

your relationship to the registrant by selecting from the list below

the document that states, “INFORMATIONAL, NOT

AND complete the attached Sworn Statement declaring that you

A VALID DOCUMENT TO ESTABLISH IDENTITY.”

are eligible to receive the Certified Copy. Your signature on the

(A sworn statement does not need to be provided.)

Sworn Statement must be acknowledged by a Notary Public if the

application is submitted by mail or fax.)

□

Identification of applicant verified

Applicant had no identification

To receive a Certified Copy I am:



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 a law enforcement agency or a representative of another governmental 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, sibling, 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.)

DO NOT complete the rest of this form before reading the detailed instructions on Page 3.

APPLICANT INFORMATION

(PLEASE PRINT OR TYPE)

Printed Name and Signature of Person Completing Application

Today’s Date

Telephone Number – Area Code First

(

)

Address – Number, Street

City

State

ZIP Code

Name of Person Receiving Copies, if Different From Above

No. of Copies

Amount Enclosed

Purpose of Request

Mailing Address for Copies, If Different From Above

City

State

ZIP Code

BIRTH CERTIFICATE INFORMATION

(PLEASE PRINT OR TYPE)

Name on Certificate – First Name

Name on Certificate – Middle Name

Name on Certificate – Last Name

City or Town of Birth

Place of Birth – County

Sex

Date of Birth – Month, Day, Year (If unknown, enter approximate date of birth)

Female

Male

Name on Certificate – Father‘s First Name

Name on Certificate – Father’s Middle Name

Name on Certificate – Father’s Last Name

Name on Certificate – Mother’s First Name

Name on Certificate – Mother’s Middle Name

Name on Certificate – Mother’s Maiden Name

BIRTH

CCR Vital 01 (Rev 01/2013)

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Form Ccr Vital 01 - Application For Certified Copy Of Birth Record - 2013

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