General laborer

INSTRUCTIONS TO COMPLETE WRITTEN APPLICATION FOR UNRESTRICTED

CERTIFIED COPY OF A BIRTH RECORD

Birth written instructions app 7/19/2013

* ***** *********** ***********:

Print or type number of copies requested

Print or type name of registrant

Print or type date of birth

Print or type city of birth

Print or type father’s name

Print or type mother’s maiden name

2

Information of the person buying certificate:

Print or type name of person buying copy

Print or type address of person buying copy

Print or type mailing address of person buying copy, if different than address above Print or type telephone number of person buying copy, including area code 3

Using the list below check the box next to the code section in item 3 on the front of this application that authorizes you to obtain an unrestricted certified copy of a birth record: 103526(c)(1) The registrant or a parent or legal guardian of the registrant 103526(c)(2) 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.

103526(c)(3) A member of a law enforcement agency or a representative of another governmental agency, as provided by law, who is conducting official business 103526(c)(4) A child, grandparent, grandchild, sibling, spouse or domestic partner of the registrant 103526(c)(5) 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 4 DO NOT COMPLETE THIS PART UNTIL YOU ARE WITH THE NOTARY PUBLIC WHO WILL PREPARE THE CERTIFICATE OF ACKNOWLEDGEMENT IN ITEM 5. Section 103526 of the California Health and Safety Code requires anyone requesting an unrestricted certified copy of a birth record to complete and sign a sworn statement under penalty of perjury. 5

Certificate of Acknowledgement

Complete items 1 to 3 on the front of this application then bring to a notary public. Complete and sign the sworn statement in item 4 in front of the notary public. Request the notary acknowledge your signature in the sworn statement in item 4. Mail the original application with the appropriate fee payable to Fresno County: Office of Vital Statistics

P.O. Box 11867

Fresno, CA 93775

559-***-****

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