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State of California - Health and Human Services Agency
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California Department of Public Health
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SWORN STATEMENT
I, ______________________________________ declare under penalty of perjury under the laws of the State of California, 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)
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(The remaining information must be completed in the presence of a Notary Public or Office of Vital Records staff.)
| Subscribed to this |
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day of |
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, 20___, at |
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, |
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(Day) |
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(Month) |
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(City) |
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(State) |
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| ______________________________________________________ |
| (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
State of ____________________)
County of ___________________)
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before me, |
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, NOTARY PUBLIC, personally appeared |
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, |
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(here insert name and title of the officer) |
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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