## 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)

(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