Application For Certified Copy Of Birth Or Death Certificate

Vital Statistics Phone: 940-349-2018 ACCEPTABLE FORMS OF PAYMENT INCLUDE: CASH, CASHIERS CHECK, MONEY ORDER, BUSINESS CHECKS, PERSONAL CHECKS AND CREDIT/DEBIT. Recording Department 940-349-2010 "NOTARIZED PROOF OF ID", a photo copy of valid ID, and appropriate payment form must be included. All forms can be found at www.dentoncounty.com/ccl or as part of this application. Application for INSTRUCTION FOR SUBMITTING APPLICATION BY MAIL: Juli Luke County Clerk Denton County Courts Building 1450 E. McKinney St. Denton, TX 76209 PHOTOCOPY OF ID MUST BE SENT IF SUBMITTING APPLICATION BY MAIL OR SUBMITTING IN PERSON. certified copy of BIRTH or DEATH Certificate BIRTH # OF CERTIFIED COPIES Please Print All Information X $23.00 (each) = $_____ Espanol en la pagina siguiente DEATH FIRST CERTIFIED COPY: $ 21.00 # OF ADDITIONAL COPIES OF SAME RECORD TOTAL ENCLOSED $ 1. Full Name (Person on Record) X $ 4.00 = $ First Middle Last 2. Date of Month Day Year 3. Sex Birth/Death 4. Place of Birth/Death 5. Full Name of Parent 1 6. Full Name of Parent 2 City or Town County State First Middle Last (Maiden) First Middle Last (Maiden) I wish to make a voluntary contribution of $5.00 to promote healthy early childhood by supporting the Texas Home Visitation Program administered by the Office of Early Childhood Coordination of the Health and Human Services. 7. Applicant's Name : 9. Mailing Address: City State Zip Code 8. Phone Daytime: 10. Relationship to Person in Item 1: 11. Purpose for obtaining this record: 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) SIGNATURE OF APPLICANT DATE APPLICATIONS WITHOUT SIGNATURE OF APPLICANT WILL NOT BE PROCESSED American LegalNet, Inc. www.FormsWorkFlow.com NOTARIZED PROOF OF IDENTIFICATION PART I. ENTER NAME, DATE AND PLACE OF BIRTH/DEATH, AND NAMES OF PARENTS AS INFORMATION APPEARS ON BIRTH/DEATH DATE OF BIRTH/DEATH FULL NAME OF PERSON ON RECORD PLACE OF BIRTH/DEATH (City or County) FULL NAME OF PARENT 1 SEX FULL NAME OF PARENT 2 PART II. ENTER RELATIONSHIP TO PERSON ON RECORD AND THE TYPE OF ID USED. NAME AND RELATIONSHIP TO PERSON ON RECORD TYPE AND NUMBER OF ID ACCEPTED WHEN NOTARIZED AFFIDAVIT OF PERSONAL KNOWLEDGE PART III. THIS SECTION MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC. STATE OF _____________________ COUNTY OF _____________________ Before me on this day appeared ____________________________ (Address) (City) (Relationship) (Name) (State) ___________ __________________ ___ who is related the contents of this affidavit are true and correct. Signature ____________________________________________________________ Sworn to and subscribed before me, this ________ day of ______________________, 20 ______. Signature of Notary Public Commission Expires (Seal) Typed or Printed Name Street Address City, State and Zip 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) MAIL THIS SWORN STATEMENT, APPLICATION, PAYMENT, AND A PHOTOCOPY OF YOUR VALID PHOTO ID TO: Denton County Clerk Vital Records 1450 E. McKinney St. Denton, TX 76209 (APPLICATIONS WITHOUT THE SWORN STATEMENT AND PHOTO ID WILL NOT BE PROCESSED, IF SUBMITTED BY MAIL) American LegalNet, Inc. www.FormsWorkFlow.com County Clerk Credit Card Payment Form Date: / / Name: ____________________________________________________ Business (optional): ___________________________________________ Phone number: (____) _____- _________ Fax: (____) ______-_______ Email: ____________________________________________________ This form authorizes the merchant (VitalChek) to charge my credit card, for services rendered by the County Clerk's office, plus a $2.50 service fee. A base percentage of 4% will be charged on credit transactions over $50.00. Please see our website for additional fees. Authorized Signature: ________________________________________ Address to send document/s: _______________________________________ _______________________________________ _______________________________________ CLERK USE ONLY TOTAL CHARGES: $_____________ *********************************************************************** * (Check which applies) Master Card Discover ____ American Express ____ Visa _____ *Name as it appears on Card: ____________________________________________ Credit Card Account Number: _--___ ______ -/ -(MM/YY) CVV# ___ ___ ___ (security code on back of card) *Exp. Date: Billing Address: ______________________ City __________________ ZIP___________ **Note** The ZI P Code must m atch the cardholder's billing address; if not, the transaction w ill be declined. ************************************************************************* Prices: · Birth Certificate: $23.00 each + credit card transaction fee · Death Certificate: $21.00 for first copy, $4.00 for each additional copy requested at same time + credit card transaction fee · Assumed Name/Abandonment of Assumed Name: $24.00 (application must be notarized) + $0.50 per additional name + credit card transaction fee · Real Property Recording: $26.00 for first page + $4.00 Recording Page + $4.00 each additional page (if applicable) + credit card transaction fee o Other fees may apply depending on document type. Please see our website for additional fees. American LegalNet, Inc. www.FormsWorkFlow.com County Clerk Personal Check Form Date: To: Denton County Clerk, Juli Luke From Name: ________________________________ Phone #: ( ) ______-_______ Personal Check: (*-information required) *First Name: ________________________________ *Last Name: ________________________________ *Mailing Address: __________________________________ *City ________*State______ *ZIP__________ *Daytime Phone# ( ) ______-_______ Department: Recording Firm:_____________________________________ *Driver's License # _________________________ *Issuing State ________ *Date of Birth ____/_____/____ *Routing #. ______________________ *Account # ____________________ *Check # __________________ Email Address___________________________________________________________________________ Providing an email address will allo