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: ___

○ Mail out

Express/Same day service (additional fee required) Revised 6/2017

Hold for Pick-Up