HomeMy WebLinkAboutFamily Member Authorization to RequestCity of College Station
Authorization for Qualified Applicant to Request Birth Certificate
Instructions:
1.Please have one of the parents fill out this form and have their signature notarized.
2.The parent MUST attach a copy of his/her valid driver’s license.
3.Once this form is completed in its entirety, the qualified authorized applicant will need to fill out an
application for the birth certificate.
4.The authorized applicant will then need to provide his/her valid driver’s license.
If you have any questions, please contact the Vital Records Office at (979)764-5016.
I _______________________ grant permission to __________________________________,
my to request a certified copy of (my/son/daughter),
,birth certificate.
My/ My son's/My daughter's date of birth is _____/_____/________.
(MM/DD/YYYY)
_________________________________Signature of Parent/Person Named on Record
_____________ Date
IMPORTANT: Arrangements must be made with the Local Rgistrars Office prior to
requesting a birth certificate on behalf of a family member in order for this release form
to be accepted.
(Parent/Person Named on Birth Record)(First & Last Name of Person Requesting Birth Record)
(Person Named on Birth Record)
(Relationship to mother/father)(Circle one)
(Circle one)
WARNING: IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE
PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT ON THIS FORM OR FOR
SIGNING A FORM WHICH CONTAINS A FALSE STATEMENT IS 2 TO 10 YEARS
IMPRISONMENT AND A FINE OF UP TO $10,000. (HEALTH AND SAFETY CODE, CHAPTER
195, SEC. 195.003)
PART I. ENTER THE REGISTRANT'S NAME, DATE AND PLACE OF BIRTH/DEATH, AND SEX.
FULL NAME OF PERSON ON RECORD DATE OF BIRTH/DEATH
PLACE OF BIRTH/DEATH (City or County) SEX
NAME AND RELATIONSHIP TO PERSON ON RECORD
AFFIDAVIT OF PERSONAL KNOWLEDGE
PART III. THIS SECTION MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC.
Signature of Notary Public
Commission Expires
Typed or Printed Name
Street Address
City, State and Zip
PART II. ENTER RELATIONSHIP TO PERSON ON RECORD AND THE TYPE OF ID USED.
SUBMIT THIS SWORN STATEMENT, APPLICATION, PAYMENT, AND A PHOTOCOPY OF YOUR VALID PHOTO ID TO:
CITY OF COLLEGE STATION
LOCAL REGISTRAR'S OFFICE
Mailing Address:
P.O. Box 9960
College Station, Texas 77842
(APPLICATIONS WITHOUT THE SWORN STATEMENT AND PHOTO ID WILL NOT BE PROCESSED)
VS-142.3(A) Rev. 09/2015 / Form No.: D-02-83 (Rev. 02/2019)
NOTARIZED PROOF OF IDENTIFICATION
(Seal)
TYPE AND NUMBER OF ID ACCEPTED WHEN NOTARIZED
STATE OF _____________________
COUNTY OF _____________________
Before me on this day appeared _____________________________________________________________________________________________
now residing at __________________________________________________________________________________________________________,
who is related to the person named on Part I as ________________________________________________________ and who on oath deposes and
says that the contents of this affidavit are true and correct.
Signature ____________________________________________________________
Sworn to and subscribed before me, this ________ day of ______________________, 20 ______.
(Name)
(Address) (City) (State)
(Relationship)
WARNING: IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY MAKING A FALSE
STATEMENT ON THIS FORM OR FOR SIGNING A FORM WHICH CONTAINS A FALSE STATEMENT IS 2 TO 10 YEARS IMPRISONMENT AND
A FINE OF UP TO $10,000. (HEALTH AND SAFETY CODE, CHAPTER 195, SEC. 195.003)
Office Address:
1101 Texas Avenue College
Station, Texas 77840