101 Grove Street, San Francisco, CA 94102 Page 1 of 3
INSTRUCTIONS FOR REQUESTING VITAL RECORDS
1. If you are requesting a Certified Informational Copy, complete only the Applicant Information and Registrant
Information portions of this form.
2. If you are requesting a Certified Authorized Copy, complete the entire form and attach the notarized Sworn
Statement. NOTARIZATION NOT NECESSARY FOR APPLICATIONS IN PERSON AT OUR OFFICE.
PLEASE NOTE: Only one notarized sworn statement is required for multiple certificates requested at the same time;
however, the sworn statement must include the name of each individual whose birth certificate you wish to obtain and
your relationship to that individual.
3. Use a separate form for each different record of birth for which you are requesting a copy. If you are requesting
Certified Authorized copies, remember to identify each registrant on the sworn statement form.
4. Submit $29 for each copy requested. Health and Safety Code 10360. The fee for any search of the files and
records performed by the custodian of the records for a specific record when no certified copy is made shall
be paid in advance by the applicant. The fee shall be the same as the fee required in Section 103625.
5. If you want the order expedited, please enclose a pre-paid, pre-addressed expedited envelope from the courier
(UPS, USPS) of your choice. Then, add an additional $30 for the expedited service fee to your total.
6. Government Requests: Health and Safety code 103660. A fee is required for making a certified copy of a vital
record for any public entity, e.g. the State, the Regents of the University of California, a county, city, district, public
authority, public agency, and any other political subdivision of public corporation in the State.
7. If you are mailing your request, payment must be in the form of a Money Order. NO PERSONAL CHECKS,
CASHIER’S CHECKS, OR CREDIT CARDS) made payable to SFDPH/OVR and mailed to:
San Francisco Office of Vital Records
101 Grove Street, Room 105
San Francisco, CA 94102
NOTE: Only San Francisco births are available through this office. Adoptees and others with legal name
changes may not be available through this office. You may contact:
California State Office of Vital Records – M.S. 5103
P.O. Box 997410 Sacramento, CA 95899-4710
Phone: (916) 445-2684
101 Grove Street, San Francisco, CA 94102 Page 2 of 3
I am: (Check the appropriate box below and circle the title, such as “child” or “attorney”)
The registrant OR parent or legal guardian of the registrant.
A party entitled to receive the record as a result of a court order, or an attorney or a licensed adoption agency seeking the Birth record
in order to comply with the requirements of Section 3140 or 7603 of the Family code. (You must present documentation to support
your relationship).
A member of a law enforcement agency or a representative of another governmental agency, as provided by law, who is conducting
official business. You must present documentation to substantiate that you are acting on official business. A business card is not
substantiation. Companies representing a government agency must provide authorization from the government agency.
A child, grandparent, grandchild, brother or sister, spouse, or domestic partner of the registrant.
An attorney representing the registrant or the registrant’s estate, or any person or agency empowered by statute or appointed by a
court to act on behalf of the registrant or the registrant’s estate. You must present documentation from the estate. A BAR card is not
substantiation. If you are requesting a Certified Copy under a power of attorney, please include a copy of the power of attorney with
this application form.
APPLICANT INFORMAT ION (PLEASE PRINT OR TYPE)
Printed Name of Person Completing Application
Today’s Date
Telephone Number – Area Code First
( )
Address – Number, Street
City
State
Zip
Email Address
Number of copies
x $29
$30 Expedite Fee
Yes
No
Total Amount Enclosed
$
Name of Person/Agency receiving copies if different from
applicant
Mailing Address (if different)
City, State, Zip Code
BIRTH INFORMATION (PLEASE PRINT LEGIBLY OR TYPE)
Middle
Last (Family)
Mother’s Maiden Name
Father’s Name
Were you adopted?
Yes
No
Did you Amend this record through the State of
California at any time?
Yes
No
NOTE: Only San Francisco Births are available through this office
BIRTH RECORD APPLICATION
I would like a Certified Authorized Copy. (To receive a
Certified Copy you MUST INDICATE YOUR RELATIONSHIP TO
THE REGISTRANT by selecting from the list below. A notarized
sworn statement must be attached.
I would like a Certified Informational Copy. This document will
be printed with a legend on the face of the document that states,
“INFORMATIONAL. NOT A VALID DOCUMENT TO
ESTABLISH IDENTITY.” A sworn statement does not need to be
provided.
City & County of San Francisco – Department of Public Health Office of Vital Records
California Health and Safety Code, Section 103526, permits only persons as defined below to receive Certified Authorized Copies of Birth
records. All others will be issued Certified Informational Copies which shall be marked “INFORMATIONAL. NOT A VALID DOCUMENT
TO ESTABLISH IDENTITY.”
FEE: $29 per copy. Please indicate whether you would like an authorized or an informational certified copy.
APPLICATION FOR A CERTIFIED COPY OF A BIRTH RECORD
NOTICE: Orders received by mail must be accompanied by the attached sworn statement (see instructions)
101 Grove Street, San Francisco, CA 94102 Page 3 of 3
SAN FRANCISCO COUNTY OFFICE OF VITAL RECORDS
SWORN STATEMENT
I, _______________________________, swear under penalty of perjury under the laws of the State of California, that I
(Printed Name)
am an authorized person, as defined on Page One (1) of this request and am eligible to receive a certified copy of the
birth and/or death record of the following individual(s):
Name of Person listed on Certificate
Relationship to Person listed on Certificate
I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
_______________________________ ____________________________________________
(Date and Place) (Signature)
Note: If submitting your order by mail, you must have your sworn statement notarized using the Certificate of
Acknowledgement below.
……………………………………………………………………………………………………………………………………………………….
CERTIFICATE OF ACKNOWLEDGEMENT
A notary public or other officer completing this certificate verifies only the identity of the individual who
signed the document, to which this certificate is attached, and not the truthfulness, accuracy, or validity of
that document.
State of _____________________________
County of _______________________________
on __________________________, before me, ___________________________________________________, Notary Public,
personally appeared __________________________________, 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,
(NOTARY SEAL)
_____________________________________________
NOTARY SIGNATURE