## 3. SWORN STATEMENT\* (Must be signed in the presence of the Pasadena Vital Records Staff or a Notary Public.)
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 certificate identified on this application form.
Subscribed to this day of , 20 , at (Day) (Month) (City) (State)
Subscribed to this
day of
20
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(Applicant's Signature)
\*If you are requesting a certified copy by mail, you must have the above statement and the certificate of acknowledgement notarized. Please note: The notary is not certifying the relationship, only that you are the person requesting the copy. Requests for an informational copy do not require your signature to be notarized.
## SUBMITTING APPLICATION
## By Mail:
Payment may be made by check or money order made payable to the City of Pasadena Public Health Department.
Do not mail cash.
Please provide a self-addressed stamped envelope.
The document(s) will be mailed to you within seven (7) business days.
## In Person:
You will be asked to present valid photo identification.
Payment may be made with a credit card (American Express, Discover, MasterCard, Visa, Debit) cash or by check/money order made payable to the City of Pasadena Public Health Department.
Please send or bring your completed application with the appropriate fee(s) to:
City of Pasadena Public Health Department Vital Records Office 1845 North Fair Oaks Avenue, Room 1610 Pasadena, CA 91103
http://ww5.cityofpasadena.net/public- health/birth- and- death- records/ (626) 744- 6010
## OFFICE USE ONLY:
ID/DL#: Exp: LRN#: BN#: City Official:
\(\bigcirc\) Mail out \(\bigcirc\) Hold for Pick- Up \(\bigcirc\) Express/Same day service (additional fee required) Page 2 of 2 Revised 6/2017