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Declaracion California Ingles

This document is a sworn statement form from the California Department of Public Health that must be completed by an authorized person to request a certified copy of a birth, death, or marriage certificate. The form requires the applicant to print their name and declare under penalty of perjury that they are eligible to receive the requested certificate. It also requires the applicant to provide their relationship to the person listed on the requested certificate. The form must be signed by the applicant in the presence of a Notary Public or CDPH Vital Records staff and notarized with a Certificate of Acknowledgment.

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Josemanuel Guzmandrito
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62 views1 page

Declaracion California Ingles

This document is a sworn statement form from the California Department of Public Health that must be completed by an authorized person to request a certified copy of a birth, death, or marriage certificate. The form requires the applicant to print their name and declare under penalty of perjury that they are eligible to receive the requested certificate. It also requires the applicant to provide their relationship to the person listed on the requested certificate. The form must be signed by the applicant in the presence of a Notary Public or CDPH Vital Records staff and notarized with a Certificate of Acknowledgment.

Uploaded by

Josemanuel Guzmandrito
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

State of California – Health and Human Services Agency California Department of Public Health

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, death, or marriage certificate of the following individual(s):

Applicant’s Relationship to Person Listed on Certificate

Name of 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 CDPH Vital Records 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 Acknowledgment
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.)
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
CERTIFICATE OF ACKNOWLEDGMENT

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.

State of _______________________)

County of ______________________)

On ____________before me, _________________________________, personally appeared _______________________________________,


(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 the 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 paragraph is true and correct

WITNESS my hand and official seal.


(SEAL)

_________________________________________________________
SIGNATURE OF NOTARY PUBLIC

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