Vital Records Authorization Form SAN BERNARDINO COUNTY RECORDER

Thank you for your recent order. Please be advised that San Bernardino County Recorder requires the following identity verification documents to process your request.

Instructions For Gathering Required Documentation

Gather your valid, government-issued photo ID (Driver's License or State-Issued ID). Photocopy your identification onto the attached Sworn Statement and Certificate of Acknowledgement. Sign and date the Sworn Statement and Certificate of Acknowledgement in the presence of a Notary Public. Submit your signed Sworn Statement and Certificate of Acknowledgement. Instructions are provided on the following page.

Vitals Records Authorization Form SAN BERNARDINO COUNTY RECORDER

Instructions For Submiting Your Documentation

OPTION 1: Using a SCANNER
1. 2. Scan the documents that you gathered in the steps on the previous page. Be sure the following information is visible on digital images of identification: Full name and address, signature, license or identification number, and expiration date. Ensure the scanned documents are saved to one or more files on your computer. Only the following file formats can be accepted: bmp, gif, jpg or jpeg, and tiff. Visit the 'My Order' page on VitalChek.com: https://www.vitalchek.com/order_status_signon.aspx Enter your order number: 28881108 and PIN: 358963 Select Upload Documents Now under #2 on the Completing Your Order page Select the scanned image file(s) that you wish to upload Attach the scanned image file(s) to your order

3.

4. 5. 6. 7. 8.

OPTION 2: Using a DIGITAL CAMERA or CAMERA PHONE

1. Take a picture of each document that you gathered in the steps on the previous page. Be sure the following information is visible on digital images of identification: Full name and address, signature, license or identification number, and expiration date Upload or email the image(s) to your computer Visit the 'My Order' page on VitalChek.com: https://www.vitalchek.com/order_status_signon.aspx Enter your order number: 28881108 and PIN: 358963 Select Upload Documents Now under #2 on the Completing Your Order page Select the uploaded image file(s) that you wish to upload Attach the uploaded image file(s) to your order

2. 3. 4. 5. 6. 7.

OPTION 3: Submitting by FAX (ONLY if you cannot use option 1 or 2 above).

You should only use the fax option if you are unable to use Option 1 or 2 above. Faxes are often rejected by government agencies because they are not legible. Faxed documentation also has to be manually linked to your order, which increases the processing time. 1. 2. 3. Use the attached Vital Records Authorization Form as your Fax Cover Sheet. Make sure all photocopies are legible. Copies of photo identification should be enlarged by approximately 200%, and lightened by 2 shades. Be sure the following information is visible on digital images of identification: Full name and address, signature, license or identification number, and expiration date Fax the Vital Records Authorization Form and any other documentation to (909)-386-8700.

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28881108
Vital Records Authorization Form SAN BERNARDINO COUNTY RECORDER
222 West Hospitality Lane San Bernardino , CA 92415

San Bernardino County Recorder 222 West Hospitality Lane San Bernardino , CA 92415 Instructions: 1. Verify that all information below is correct. 2. Print and complete this form. 3. Sign and date the form (If notarization section is included below, signature must occur in the presence of a Notary Public.) 4. Fax the signed form to (909)-386-8700. 5. Please fax only the Authorization Form. Do not include a cover sheet. Sworn Statement I, ___________________________, agree not to use the record obtained from this application or any portion thereof, for fraudulent purposes. I am signing my own legal name and I am an authorized person, as shown in the Health and Safety Code Section 103526(c) , and am eligible to receive a certified copy of the birth, death or marriage record of the following individual. I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Name of Person Listed on Certificate Relationship to Person Listed on Certificate

VitalChek Order Number: 28881108 PIN: 358963

Birth - Authorized Copy : Dennis Bennett Sworn this

Self

______ ay of ________, 20____ at __________________________ d , _______. (Day) (Month) (City) (State)

____________________________________ Signature -------------------------------------------------------------------------------------------------------------------------------------------------------------------

Certificate of Acknowledgment
State of County of On _____________, before me, appeared,
(insert name of person signing)

) ) ss ) , NOTARY PUBLIC
(insert name and title of officer)

, personally

, 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 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.

(NOTARY SEAL) _______________________________________ Notary Signature

28881108
Vitals Records Authorization Form SAN BERNARDINO COUNTY RECORDER

Vital Records Authorization Form (Photo Identification Page) San Bernardino County Recorder 222 West Hospitality Lane San Bernardino , CA 92415 VitalChek Order Number: 28881108 PIN: 358963

IMPORTANT! When making a copy of your ID to place here, enlarge and lighten it to aid identification. This will reduce the processing time.