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Identification, Benefits & Income

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Identification, Benefits & Income IDENTIFICATION, BENEFITS & INCOME IDENTIFICAIN BITH CERTIFIAE WR TO G I IFIAE DPNDS N WE OU W N Born in City and County of San Francisco G A IFID P F YOUR I IFIAE ST: 25 ayent etod: VISA, ater Card ca oney order or perona or buine cec payabe to epartent of ubic eat ffice of the ount ler ity al oo 162 r arton oodett Place an rancico 02 one 554-4950 our a – p onday – riday (coed aor oliday) & INCOME BENEFITS ID, In Person: You are required to complete an “Application for Certified Copy of Birth Record,” and preent aid lea poto rocein time for order in peron i approiatey inutes. You ut no ti inforation to fill out te for ul nae at birt ate of birt Mother’s Ful ae at irth Father’s Full Name Place of irt opita nae if non) Born in California – Outside of San Francisco all the alifornia Department of ealth Serice (916) -268 for information G A IFID P F YOUR I IA ot 25 InPeron euest – County Recorder’s Office The best option is to go to the Recorder’s Office in the county in which you were born. BEFOR -- all te aifornia epartent or ounty office and a uestion includin o you need to o identification to et te birt certificate o on doe it tae to et te birt certificate 41 iedn Reuest – Ciforni ertent of et erices If you can’t make it to another county’s Recorder’s Office, you can mail the request. California Department of ealth Serices Office of ital Records M.S. 3 P.O. Bo 410 Sacramento, CA 899-7410 O ECO E OO OR I REQUEST: Chec or money order made out to California Department of ealth Serices for 25 Birth Certificate Application and Sworn Notarized Statement Formal written or typed request for birth certificate – A sample can be found at the end of this section. ORNT ORO EN O MAI REQUEST hen requests for birth certificates are mailed in, you must submit a sorn notried stteent along with the application. You will see that this statement is attached to the standard application. A Notary is someone who is legally empowered to witness signatures and certify a documents validity. There are many businesses that hae a notary on staff. One suggestion is the PS Store at 4th Street, San Francisco, CA 107. Phone: (415 5-696. There is a fee for the notaried serice – Fees may ary from place to place. To get a notaried statement, you need documentation of your identity, age, and legal presence. If you don’t yet have any personal identification, try to get a statement from your probation or parole officer that testifies to your name, age, birth date, address, and parents’ legal names. Also, bring a close family member who has I.D. with you to the notary. The notary may allow your family member to “verbally identify” you. Remember, to mail in a birth certificate request, you need to include four things: The application, fee, notaried statement, and written letter. t tes out dys for mied in reuest to be rocessed Bo ornia Call the Recorder’s Office in the county in which you were born and ask several questions: Can a family member with identification who still lives in the county request the birth certificate hat is the application process for an inperson request ow much does it cost ow long does it tae to receie it? hat is the application process for a mailedin request 42 ale etter Requesting irth Certificate f ou re ailin in the Request ate o hom It ay oncern: his is a formal request to receive a RII O of my birth certificate. y legal name is elly inda ones and I as born in an rancisco ounty in . nclosed is my payment for 25 and the application for a birth certificate hich includes the sorn notaried statement. lease mail the birth certificate to elly ones 850 ryant treet an rancisco, 94103 & INCOME ID, BENEFITS ID, his is my permanent residence. I can be reached at 555-5555 if you have questions about any of the submitted information. hank you in advance for your assistance ith this request. incerely, elly ones 43 State of California – Health and Human Services Agency California Department of Public Health APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD PLEASE READ THE INSTRUCTIONS ON PAGE 2 BEFORE COMPLETING THIS APPLICATION As part of statewide efforts to prevent identity theft, California law (Health and Safety Code Section 103526) permits only authorized individuals as listed on the application to receive certified copies of birth records. All others will be issued Certified Informational Copies marked with the legend, “Informational, Not A Valid Document to Establish Identity.” Please indicate the type of certified copy you are requesting: I would like a Certified Copy. This copy will establish the identity of I would like a Certified Informational Copy. This document will be the registrant. (To receive a Certified Copy you MUST INDICATE printed with a legend on the face of the document that states, YOUR RELATIONSHIP TO THE REGISTRANT by selecting from the list “INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY.” below AND COMPLETE THE ATTACHED SWORN STATEMENT declaring that you are eligible to receive the Certified Copy. The (A Sworn Statement does not need to be provided.) Sworn Statement MUST BE NOTARIZED if the application is submitted by mail unless you are a law enforcement or local or state governmental agency.) NOTE: Both documents are certified copies of the original document on file with our office. With the exception of the legend and redaction of signatures and Social Security Number, the documents contain the same information. Fee: $25 per copy (payable to CDPH Vital Records). PLEASE SUBMIT CHECK OR MONEY ORDER – DO NOT SEND CASH PLEASE ATTACH CHECK (CDPH cannot be held responsible for fees paid in cash that are lost, misdirected, or undelivered). To receive a Certified Copy I am: The registrant (person listed on the certificate) or a parent or legal guardian of the registrant. (Legal guardian must provide documentation.) 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. (Please include a copy of the court order.) 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, brother or sister, spouse, or domestic partner of the registrant. HERE 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. Appointed rights in a power of attorney, or an executor of the registrant’s estate. (Please include a copy of the power of attorney, or supporting documentation identifying you as executor.) APPLICANT INFORMATION (PLEASE PRINT OR TYPE) Today’s Date: Agency Name (If Applicable) Agency Case Number Inmate ID Number Print Name of Applicant Signature of Applicant Purpose of Request Mailing Address – Number, Street Amount Enclosed – DO NOT SEND CASH Number of Copies $ _______ Check $ ______ Money Order City Name of Person Receiving Copies, if Different from Applicant State/Province ZIP Code Mailing Address for Copies, if Different from Applicant Daytime Telephone (include area code) Country City State ZIP Code ( ) BIRTH RECORD INFORMATION (PLEASE PRINT OR TYPE) Adopted: No Yes (If Yes, see #4 on Page 2) Complete the information below as shown on the birth record, to the best of your knowledge. FIRST Name MIDDLE Name LAST Name City of Birth (must be in California) County of Birth Date of Birth – MM/DD/CCYY (If unknown, enter approximate date of birth) Sex ___Female ___Male Father/Parent FIRST Name MIDDLE Name LAST Name (Before Marriage/Domestic Partnership) Mother/Parent FIRST Name MIDDLE Name LAST Name (Before Marriage/Domestic Partnership) BIRTH VS 111 (01/14) Page 1 of 3 44 INFORMATION: Birth records have been maintained in the California Department of Public Health Vital Records since July 1, 1905. The name required on Vital Records (see Items 1C, 6C, 7C, 9C, and 12C) is the name given at birth, or a name received through adoption, court‐ordered name change, or naturalization. AKAs (Also Known As) and assumed names cannot be entered as the legal name on the birth record. INSTRUCTIONS: 1. 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 identifies 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 Record section of our website at: www.cdph.ca.gov. Only specific individuals may obtain confidential copies. 2. Complete a separate application for each birth record requested. 3. Complete the Applicant Information section on Page 1 and provide your signature where indicated.
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