VitalChek - Ordering By Fax

Riverside County Recorder - Vital Records
Birth Authorized Copy
Print this form, complete it and fax it to 8883876984

Certificate Holders Name	____________________________________________________________________________
	(first middle last)
Father's Name	____________________________________________________________________________
	(first middle last)
Mother's Maiden Name	____________________________________________________________________________
	(first middle last)

Date of Birth

__________________

County/City

__________________________________

State_______

Hospital

__________________________________________________________

Male Female

Relationship (MUST be an AUTHORIZED person):

_______________________________________________________

Reason for request

__________________________________________________

Number Of Copies

_______

Ship Method:	Express Courier (additional charges) Regular Mail
Ship To Name	_________________________________________________________________________________
Address	_________________________________________________________________________________
City	________________________________________________ State ________ Zip ______________
Daytime Phone	____________________
Credit Card: Visa MasterCard American Express Discover

Credit Card Number	_____________________________________________________	Expires	_____________
Cardholder's Signature	_____________________________________________________	Date	_____________
Applicant's Signature	_____________________________________________________	Date	_____________
Applicant's Email:	_____________________________________________________

Credit Card Billing Address

Name ______________________________________________

Address ____________________________________________

City _________________________ State ____ Zip ________

SWORN STATEMENT

______________________________________,

(Print Name)

swear/affirm 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	Relationship to Person Listed on Certificate

Sworn this	______	day of	___________,	20____, at	________________________,	_________.
	(Day)		(Month)		(City)	(State)

_____________________________________________________

(Signature)

Note: If submitting your order, you must have your sworn statement notarized using the Certificate of Acknowledgment below.

CERTIFICATE OF ACKNOWLEDGMENT

State of	_________________	)
		) ss
County of	_________________	)

On	_____________,	before me,	__________________________________________________________,	personally
			(insert name and title of officer)

appeared,	____________________________________________________,	who proved to me on the basis of
	(insert name of person signing)

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 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.

(NOTARY SEAL)

_______________________________________
Notary Signature