Texas > Local County > Fort Bend > Miscellaneous
Application For Birth Or Death Certificate - Texas
| Application For Birth Or Death Certificate Form. This is a Texas form and can be used in Miscellaneous Fort Bend Local County . |
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OFFICE USE ONLY CERT #___________ DOCUMENT CONTROL # ________________________ ________________________ ________________________ BY: _____________________ Dr. Dianne Wilson, Ph.D. Fort Bend County Clerk 301 Jackson, Suite 101 Richmond, Texas 77469-3108 Phone: (281) 341-8685 Fax: (281) 341-8669 OFFICE USE ONLY RECEIPT #________________ AMOUNT $________________ CASH__ CREDIT__ OTHER__ DATE____________________ BY:______________________ APPLICATION FOR BIRTH OR DEATH CERTIFICATE BIRTH CERTIFICATE _____ Certified Copies Requested @$23.00 each = _________ (NO PERSONAL CHECKS, PLEASE) 1. PLEASE PRINT DEATH CERTIFICATE _____Certified Copies Requested $21.00 First Copy $4.00 Additional Copies of same record/same request Last Name Full Name of Person on Record First Name Middle Name 2. Date of Birth or Death Month Day Year 3. Sex 4. Place of Birth or Death City or Town County State 5. Full Name of Father First Name Middle Name Last Name 6. Full Maiden Name of Mother First Name Middle Name Last Name 7. 9. APPLICANT'S NAME: __________________________________________ 8. TELEPHONE # ( ) _______________________ (MON-FRI 8:00-5:00) MAILING ADDRESS: __________________________________________________________________________________________ STREET ADDRESS CITY STATE ZIP 10. RELATIONSHIP TO PERSON NAMED IN ITEM 1: ______________________________________________________ 11. PURPOSE FOR OBTAINING THIS RECORD: ______________________________________________________________________ 12. ADDITIONAL IDENTIFYING INFORMATION FOR DEATH CERTIFICATE: SOCIAL SECURITY NUMBER OF DECEASED _____________________________________________________________________ BIRTH DATE __________________ BIRTH PLACE, ETC. ________________________________________ WARNING: THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT IN THIS FORM CAN BE 2-10 YEARS IN PRISON AND A FINE OF UP TO $10,000. (HEALTH AND SAFETY CODE, CHAPTER 195, SEC. 195.003) ______________________________________________ YOUR SIGNATURE OFFICE USE ONLY ______________________________________________ IDENTIFICATION TYPE (DL, ID CARD, ETC.) _________________________________ DATE OF APPLICATION _______________________________________________ NUMBER (ON DL, ID CARD, ETC.) IF REQUESTING BY MAIL, PLEASE INCLUDE PHOTO COPY OF DL / ID CARD i:\vitals\bc_dc application American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS FOR APPLICATION FOR CERTIFIED COPY OF A BIRTH OR DEATH CERTIFICATE Indicate the number of records requested and compute the amount of money to be sent. PLEASE DO NOT SEND CASH THROUGH THE MAIL. WE SUGGEST YOU SEND A MONEY ORDER MADE PAYABLE TO: FORT BEND COUNTY CLERK. NO CHECKS PLEASE. Item 1. Item 2. Name on Record: State the FULL NAME of the person shown on the record being requested. Date of Event: (The date of the Birth OR Death) Give the exact date of the birth or day the person died. (If you do not know the exact date of death, then give the date the person was last known to be alive.) Sex: Enter Male or Female. Place of Event: State the name of the city or county in which the birth or death occurred. (If you do not know the exact place of death, show the last address known when the person was alive.) Father's Name: Give the full name of the father of the person shown on the record. Mother's Maiden Name: Give the FULL MAIDEN NAME of the mother of the person shown on the record. Applicant's Name: Give YOUR full name Item 3. Item 4. Item 5. Item 6. Item 7. Item 8. Telephone Number: Give us the telephone number with area code where you can be reached between the hours of 8 a.m. and 5 p.m., Monday through Friday. Mailing Address: Give us the complete current mailing address. Relationship to person named on the record: State how you are related to the person whose record you are requesting. Purpose for obtaining this record: State the reason or purpose for which you are requesting this record. ADDITIONAL IDENTIFYING INFORMATION FOR DEATH CERTIFICATE: This additional information assists our staff in positively identifying a record when exact dates, places and spelling of the name(s) are not known for a death certificate: Social Security Number of the deceased Birthdate of the deceased Birthplace of the deceased Any other information that would be helpful in identifying the record of an individual. Item 9. Item 10. Item 11. Item 12. NOTE: FEES ARE SUBJECT TO CHANGE WITHOUT NOTICE (CALL 281.341.8685 FOR FEE VERIFICATION). THE SEARCHING FEE IS NON-REFUNDABLE EVEN IF A RECORD IS NOT FOUND. BIRTH RECORDS ARE CONFIDENTIAL FOR 75 YEARS AND DEATH RECORDS ARE CONFIDENTIAL FOR 25 YEARS; THEREFORE ISSUANCE IS RESTRICTED. OTHER RECORDS MAY BE OBTAINED WHEN SUFFICIENT INFORMATION FOR IDENTIFICATION IS PROVIDED. A VALID PHOTO ID IS REQUIRED PRIOR TO RECEIVING SERVICE. A PHOTOCOPY OF A VALID PHOTO ID MUST ACCOMPANY THE APPLICATION WHEN RETURNING BY MAIL OR FAX. FAILURE TO PROVIDE REQUIRED INFORMATION MAY CAUSE YOUR REQUEST TO BE REJECTED. American LegalNet, Inc. www.FormsWorkflow.com
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