INSTRUCTIONS

COPIES REQUESTED

THE FEE FOR EACH CERTIFICATION MUST BE SUBMITTED WITH THIS APPLICATION AND A COPY OF YOUR DRIVERS LICENSE

PLEASE TYPE OR PRINT LEGIBLE.

CERTICATE OF BIRTH $23.00 EACH

HOW MANY?___________________________

AMOUNT ENCLOSED $__________________

PLEASE INCLUDE I.D. INFORMATION      SHORT FORM CERTIFICATE

D.L. NUMBER_______________________           CASH OR MONEY ORDER

STATE ISSUED______________________                                   ONLY

INFORMATION ABOUT PERSON WHOSE BIRTH CERTIFICATE IS REQUESTED

1. NAME AT BIRTH

FIRST

MIDDLE

LAST

2. DATE OF BIRTH

MONTH

DAY     /   YEAR

3. SEX

4. PLACE OF BIRTH

CITY OR TOWN

COUNTY

STATE

5. MOTHERS NAME

FULL NAME

FIRST

MIDDLE

MAIDEN NAME

6. FATHERS NAME

FULL NAME

FIRST

MIDDLE

LAST

PERSON REQUESTING CERTIFICATION OF BIRTH

7. PURPOSE OF WHICH CERTIFICATION OF BIRTH IS TO BE USED (SCHOOL, EMPLOYMENT, MILITARY, PASS PORT, ETC.)

8. RELATIONSHIP TO PERSON NAMED IN ITEM 1 ABOVE (SELF, MOTHER, ATTORNEY, ETC.)

9. PRINTED NAME OF APPLICANT

10. ADDRESS OF APPLICANT                      STREET ADDRESS

CITY                                                                                       STATE                                                     ZIP

11. SIGNATURE OF APPLICANT                                                                   12. DATE SIGNED

IF YOU WANT THE CERTIFICATION OF BIRTH MAILED TO SOME OTHER PERSON, COMPLETE THIS SECTION

PLEASE COMPLETE THIS FORM AND RETURN WITH FEE AND COPY OF APPLICANTS DRIVERS LICENSE TO THE ADDRESS ABOVE.

NAME

STREET ADDRESS

DO NOT WRITE IN THIS SPACE

CLERK____________________________________

LICENSE #_________________________________

CITY OR TOWN                                  STATE                                  ZIP

WARNING: The penalty for knowingly making a false statement in this form can be 2

10 years in prison and a fine up to $5,000. (Article 4477c, Revised Civil Statutes of Texas)