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State of California – Health and Human Services Agency Department of Public Health APPLICATION FOR CERTIFIED COPY OF MARRIAGE OR DIVORCE RECORD DO NOT Complete This Application Before Reading the Instructions on Page 2 I would like a Certified Copy. This copy will establish the identity of the registrant. (To receive a Certified Copy you MUST INDICATE YOUR RELATIONSHIP TO THE REGISTRANT (select from the list below) AND COMPLETE THE ATTACHED SWORN STATEMENT declaring that you are eligible to receive the Certified Copy. The Sworn Statement MUST BE NOTARIZED if the application is submitted by mail unless you are a law enforcement or local or state governmental agency.) I would like a Certified Informational Copy. This document will be printed with a legend on the face of the document that states, “INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY.” (A Sworn Statement does not need to be provided.) Fee: $14 per copy for Marriage Record - $13 per copy for Divorce Record NOTE: Both documents are certified copies of the original document on file with our office. With the exception of the legend, the documents contain the exact same information. To receive a Certified Copy I am: The registrant (person listed on the certificate) or a parent or legal guardian of the registrant (legal guardians should provide documentation). A party entitled to receive the record as a result of a court order (please include a copy of the court order). A member of a law enforcement agency or a representative of another governmental agency, as provided by law, who is conducting official business. (Companies representing a government agency must provide authorization from the government agency.) A child, grandparent, grandchild, brother or sister, spouse, or domestic partner of the registrant. 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. (If you are requesting a Certified Copy under a power of attorney, please include a copy of the power of attorney with this application form.) PLEASE TYPE OR PRINT THE INFORMATION REQUESTED BELOW EXCEPT WHERE SIGNATURE IS REQUIRED APPLICANT INFORMATION – You MUST Complete This Section (PLEASE PRINT OR TYPE) Purpose for Which Certified Copy is to Be Used Today’s Date Area Code and Telephone ( ) Name of Person Completing Application Signature of Person Requesting Record(s) Mailing Address – Number, Street City Name of Person Receiving Copies, if Different From Above Number of Copies Mailing Address for Copies, if Different From Above City State Amount Enclosed ZIP Code Purpose of Request State ZIP Code MARRIAGE CERTIFICATE: Complete First and Second Person Information Birth Last Name Name of First Person – First Name Middle Name Current Last Name Date of Birth Place of Birth Name of Father/Parent of First Person Name of Second Person – First Name Middle Name Current Last Name Date of Birth Place of Birth Name of Father/Parent of Second Person Date of Marriage – Month, Day, Year If Date Unknown, Enter Year(s) to be Searched County That Issued License Birth Last Name County of Marriage DIVORCE CERTIFICATE: Complete First and Second Person Information Name of First Person – First Name Middle Name Current Last Name Birth Last Name Name of Second Person – First Name Middle Name Current Last Name Birth Last Name Date of Divorce – Month, Day, Year If Date Unknown, Enter Year(s) to be Searched County of Divorce MARRIAGE Page 1 of 3 VS 113-A (01/2010) INFORMATION: Public Marriage Records: Maintained in the Office of Vital Records (OVR) since July 1, 1905. 1905 Through 1948, 1987 Through 1997, and 2000 to Present: While we do preserve these records in our office, due to the timeconsuming process of searching marriage records, we are not able to provide certified copies of certificates for these years. You will need to contact the County Recorder in the county where the license was issued. 1949 Through 1986, and 1998 Through 1999: Due to the increased and urgent need for certified copies of birth certificates as proof of identity, OVR is experiencing lengthy delays in the processing time for marriage records. Since this processing time can easily exceed six months, you should submit your request for a marriage record to the County Recorder’s Office in the county where the marriage license was issued. • Confidential Marriage Records: We do not maintain confidential marriage records. Contact the County Clerk’s Office in the county where the marriage license was issued. • Divorce Records: Maintained only for the years 1962 through June 1984. For these years, we are only able to provide you with a Certificate of Record, which identifies the names of the parties, filing date, county, and case number of the divorce. Copies of the actual divorce decree can only be obtained from the Superior Court in the county where the divorce took place. Our processing time for divorce records can be quite lengthy and may exceed six months. INSTRUCTIONS: 1. Use a separate application for each different record that you are requesting. Include $14 for each marriage and $13 for each divorce record request. If we cannot locate the record based on the information you provide, state law requires that we keep the fee (for our searching efforts), but we will provide you with a “Certificate of No Public Record.” 2. Provide as much information as possible to help us locate the specific record you are requesting. Complete First and Second Person Information for marriage requests, and/or divorce requests. If the information you provide is incomplete or inaccurate, we may not be able to locate the record. 3. Identify the number of copies you want. Include a check or money order (for out-of-country requests, use an international money order payable in U.S. dollars) made payable to the Office of Vital Records. Mail this application with the fee(s) to the Office of Vital Records at the address below. 4. SWORN STATEMENT: • • If the application is being submitted by mail, the Sworn Statement must be notarized by a Notary Public. (To find a Notary Public, see your local yellow pages or call your banking institution.) Law enforcement and local and state governmental agencies are exempt from the notary requirement. • 5. The authorized individual requesting the certified copy must sign the attached Sworn Statement, declaring under penalty of perjury that they are eligible to receive the certified copy of the marriage record, and identify their relationship to the registrant(s) – their relationship must be one of those identified on Page 1. You do not have to provide a Sworn Statement if you request a “Certified Informational Copy” of the marriage record. Returning Completed Certificates: Completed certificates are returned using the U.S. Postal Service. Office of Vital Records – MS 5103 P.O. Box 997410 Sacramento, CA 95899-7410 (916) 445-2684 MARRIAGE Page 2 of 3 VS 113-A (01/2010) State of California – Health and Human Services Agency California Department of Public Health SWORN STATEMENT I, ___________________________________, declare under penalty of perjury under the laws of the State of California, (Applicant’s Printed Name) that I am an authorized person, as defined in California Health and Safety Code Section 103526 (c), and am eligible to receive a certified copy of the birth, death, or marriage certificate of the following individual(s): Applicant’s Relationship to Person Listed on Certificate Name of Person Listed on Certificate (Must Be a Relationship Listed on Page 1 of Application) (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) (City) (State) ______________________________________________________ (Applicant’s Signature) Note: If submitting your order by mail, you must have your Sworn Statement notarized using the Certificate of Acknowledgment below. The Certificate of Acknowledgement must be completed by a Notary Public. (Law enforcement and local and state governmental agencies are exempt from the notary requirement.) -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CERTIFICATE OF ACKNOWLEDGMENT State of _______________________) ) 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 VS 113-A (01/2010) Page 3 of 3