Instructions to Complete the Request for Birth Certificate
1. Indicate whether you are requesting a Certified Copy or a Certified Informational Copy.
Only individuals who are authorized by Health and Safety Code §103526 can obtain a Certified Copy of a birth record. Section C
on page 1 of the application identifies the individuals who are authorized to receive a Certified Copy. All others may receive a
Certified Informational Copy that will be marked “Informational, Not a Valid Document to Establish Identity.”
Both documents are certified reproductions of the original document on file with our office. With the exception of the legend,
redaction of signatures and Social Security Number, the documents contain the same information.
2. Section A
In this section, please provide the information about the child. If the information furnished is incomplete or inaccurate, we may
not be able to locate the record.
The “Birth” name required on Vital Records is the name given at birth, or a name received through adoption, court-
order name change, or Naturalization. AKAs (Also Known As) and assumed names cannot be entered as the legal
“Birth” name.
3. Section B
In this section, please provide your information, the number of copies requested and the amount enclosed. The fee is $32.00 for
each copy requested.
Make the check or money order payable to: County of Riverside
❖ No third-party checks or money orders are accepted
❖ Checks must have pre-printed name and address of checking account owner
State law requires a charge for record searches. If no record is found, pursuant to Health and Safety Code §103650,
the fee for one certificate will be retained for searching and a Certificate of No Record will be issued. If requesting
multiple copies on the application, the balance will be refunded to the applicant by our Fiscal Department after the search fee is
retained.
4. Section C: Skip this section if you are requesting a Certified Informational Copy.
Establish your relationship to the person listed on the certificate by marking only one (1) box in this section.
5. Section D: Skip this section if you are requesting a Certified Informational Copy.
Section D has two parts.
❖ Sworn Statement: Everyone requesting a Certified Copy must complete the Sworn Statement. The applicant requesting the
Certified Copy must sign the Sworn Statement declaring under penalty of perjury that he/she is eligible to receive the
Certified Copy of the birth record. The applicant must print his or her name, print the name of the child, and identify his/her
relationship to the child. The relationship MUST match the information in Section C, page 1. Sign the Sworn Statement in
the presence of a Notary Public or an employee of the Office of Vital Records.
❖ Certificate of Acknowledgment: The Certificate of Acknowledgment is to be completed by a Notary Public. Law enforcement
and local and state government agencies are exempt from the notary requirement.
6. Mail completed application to:
Office of Vital Records
P.O. Box 7600
Riverside, CA 92513-7600
If you have any questions, please call the Riverside County Office of Vital Records at: 951-358-5068.
Third-Party
Riverside County Department of Public Health Office of Vital Records
MAIL APPLICATION FOR CERTIFIED COPY and CERTIFIED INFORMATIONAL COPY OF BIRTH RECORD
Only 2022 and 2023 records are available from our office.
Please indicate the type of record you are requesting
□ I would like a Certified Copy. $32.00 per copy
Complete Sections A, B, & C, then complete D in the
presence of a Notary Public
Only specific people are eligible to receive this record. This
document will establish the identity of the registrant. Refer to
Section C to see if you are eligible. If not, you must request a
Certified Informational Copy.
□ I would like a Certified Informational Copy. $32.00 per copy
Complete only Sections A & B. (skip Sections C & D)
No Sworn Statement and No Notary Required
Everyone is eligible to request this record.
This document will be printed with a legend on the face of the
document that states: “INFORMATIONAL, NOT A VALID
DOCUMENT TO ESTABLISH IDENTITY.”
Section A: BIRTH CERTIFICATE INFORMATION (please print or type)
Complete the information below as shown on the birth record to the best of your ability.
The more information you provide, the easier it is for us to be sure you get the correct record.
FIRST NAME of Child
MIDDLE NAME of Child
Date of Birth
City of Birth
Mother/Parent FIRST name
MIDDLE name
Father/Parent FIRST name
MIDDLE name
Section B: Your Information: “Applicant” (please print or type)
Your First Name Your Middle Name Your Last Name
Your mailing information:
Street Address:
__________________________________________
City, State, Zip Code:
Make check or money orders payable
to: County of Riverside.
We do not accept third-party checks.
This means the name on the check or
money order must be the same as the
name of the applicant.
Your Daytime Telephone
( )
Number of Copies Requested:
Section C: RELATIONSHIP TO CHILD (complete only if requesting a Certified Copy)
Check the box that establishes your relationship to the person listed on the certificate. I am:
□ A parent or legal guardian of the registrant (person listed on the certificate).
□ A child, grandparent, grandchild, brother or sister, spouse, or registered domestic partner 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. Please include a copy of the court order.
□ A member of a law enforcement agency or other government agency, as provided by law, who is conducting official business.
Companies representing a government agency must provide authorization from the government agency.
□ 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.
□ Appointed rights in a power of attorney. The principal (person authorizing the other to act) must be qualified to receive a certified
copy. Please include a copy of the power of attorney
□ An executor of the registrant’s estate. Please include supporting documentation identifying you as executor.
DOPH_VR_BirthMail (Effective 01/01/2023, Rev. 12/1/2022) Page 1 of
2
Be advised, we charge even if no record is found. Pursuant to H&S Code §103650 if no record is found, a
fee equal to the cost for one certificate will be retained for searching and a “Certificate of No Record” will be
issued.
(Office Use Only)
Date Received
LRN: _______________________
AMENDMENT
COUNT: 0 1 2 3
Riverside County Department of Public Health Office of Vital Records
Section D: SWORN STATEMENT AND CERTIFICATE OF ACKNOWLEDGMENT
SWORN STATEMENT
I, _______________________________________, declare under penalty of perjury under the laws of the State of
(Your Printed Name)
California, that I am an authorized person, as defined in California Health and Safety Code §103526 (c), and am eligible to receive a
certified copy of the birth record of the following individual:
Name of Person Listed on the Certificate:_______________________________________________
(this is the name of the child)
Your Relationship to the Person named above: __________________________________________
(this must match the relationship indicated in Section C on page 1)
*******The remaining information must be completed in the presence of a Notary Public or Office of Vital Records staff.*******
Subscribed to this ________day of _______________, 20______, at ____________________________, ______________.
(Day) (Month) (Year) (City) (State)
_____________________________________________
(Your Signature)
If submitting your order by mail, you must have your Sworn Statement notarized using the Certificate of
Acknowledgment below. The Certificate of Acknowledgment is compliant with California law (Civil Code
§1189) and must be completed by a Notary Public. If you are not in California, please strike out California and
insert the appropriate state.
Law Enforcement and local and state government agencies are exempt from the notary requirement.
CERTIFICATE OF ACKNOWLEDGEMENT
State of California )
County of __________________)
On________________before me, ______________________________________personally appeared
(here insert name and title of the officer)
___________________________________, 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.
(SEAL)
_____________________________________
SIGNATURE
DOPH_VR_BirthMail (Rev. 12/1/2022) Page 2 of 2
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.