Form Ccr Vital 08 – Fill Out and Use This PDF

MARK A. LUNN

VENTURA COUNTY CLERK AND RECORDER

APPLICATION FOR CERTIFIED COPY OF A MARRIAGE RECORD

Effective January 1, 2010, California State Law, Health and Safety Code Section 103526, permits only authorized persons as defined below to receive certified copies of marriage records.

Note: If the marriage license was not issued in Ventura County, then the Ventura County Clerk/Recorder will not have the marriage certificate. Please order the marriage certificate from the Recorder or County Clerk of the county where the license was issued.

Fees: $14 per copy (payable to the Ventura County Clerk and Recorder). If no record of the marriage is found, the $14 fee will be retained for searching the record (as required by law) and a Certificate of No Record will be issued to the applicant. Copies may be obtained in person or by mail at: Ventura County Clerk and Recorder 800 S. Victoria Ave. Ventura CA 93009-1260

Please indicate the type of certified copy you are requesting:

DO NOT complete the rest of this form before reading the detailed instructions on Page 3.

APPLICANT INFORMATION (PLEASE PRINT OR TYPE)

Printed Name and Signature of Person Completing Application			Today’s Date	Telephone Number – Area Code First
				(	)
Address – Number, Street	City			State		ZIP Code
Name of Person Receiving Copies, if Different From Above	No. of Copies	Amount Enclosed		Purpose of Request
Mailing Address for Copies, If Different From Above	City			State		ZIP Code

NAMES OF BOTH PARTIES TO THE MARRIAGE (PLEASE PRINT OR TYPE)

First Name	Middle Name	Last Name as listed on marriage certificate
First Name	Middle Name	Last Name as listed on marriage certificate
Date of Marriage – Month, Day, Year	County Where License was issued	County of Marriage

CCR VITAL O8 (Rev 08/2010)

Page 1 of 3

Ventura County Clerk and Recorder

SWORN STATEMENT

(*Required for certified copy of record. This Sworn Statement is not required when requesting an Informational certified copy which is not valid to establish identity)

*Any member of a law enforcement agency or a representative of a state or local government agency, as provided by law, who orders a copy of a record to which subdivision (a) applies in conducting official business must complete the Sworn Statement, however, they may not be required to have their signature on the Sworn Statement acknowledged by a Notary Public.

I, _________________________________, declare under penalty of perjury under the laws of the State of California,

(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 marriage certificate of the following individual(s):

(The remaining information must be completed in the presence of a Notary Public or County Clerk and Recorder staff.)

Subscribed to this _______ day of ______________, 20___, at _________________________, ________________.

(Day)(Month)(City)(State)

______________________________________________________

(Signature of person requesting certified copy)

Note: If submitting your order by mail or fax, you must have your signature on the Sworn Statement acknowledged by a Notary Public using the Certificate of Acknowledgment below. If submitting your order in person, you must sign this in the presence of the County Clerk and Recorder staff.

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

CERTIFICATE OF ACKNOWLEDGMENT

State of ____________________)

) ss

County of ___________________)

On ________________, before me, _______________________________________________________________, personally

(Insert your name and title)

appeared __________________________________________________________________________, who proved to me on the

basis of satisfactory evidence to be the person(s) whose name 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.

(NOTARY SEAL)

_______________________________________________________

NOTARY SIGNATURE

Page 2 of 3

CCR VITAL 08 (Rev 08/2010)

INSTRUCTIONS:

1.As of January 1, 2010, ONLY individuals who are authorized by Health and Safety Code Section 103526 can obtain a Certified Copy of a Non-Confidential Marriage Record. (Page 1 of the application identifies

the individuals who are authorized to make the request.) All others may receive a Certified Informational

Copy which will be marked, “Informational, Not a Valid Document to Establish Identity.” Certified copies of confidential marriage certificates are only available to the parties of that confidential marriage. Informational copies are not available for confidential marriage certificates.

2.Complete a separate application form for each record of public marriage certificate requested.

3.Complete the Applicant Information section on the first page of this form and provide your signature where indicated. Provide all the information you have available to identify the record of the registrant under Marriage Certificate Information. If the information you furnish is incomplete or inaccurate, it may be impossible to locate the record.

4.SWORN STATEMENT:

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.

If the application is being submitted by mail, your signature on the Sworn Statement must be acknowledged by a Notary Public. (To locate a Notary Public, see your local yellow pages or call your banking institution.).

Any member of a law enforcement agency or a representative of a state or local government agency, as provided by law, who orders a copy of a record to which subdivision (a) applies in conducting official business is required to complete the Sworn Statement, however, they may not be required to have their signature on the Sworn Statement acknowledged by a Notary Public.

If the application is being submitted in person at the County Clerk and Recorders Office, the

Sworn Statement must be signed by you in the presence of the County Clerk and

Recorder staff, and your signature does not have to be acknowledged by a Notary Public.

A Sworn Statement does not need to be provided if you are requesting a Certified Informational Copy of a non-confidential (public) marriage record.

5.Submit $14 for each certified copy requested. If no record of the marriage is found, the $14 fee will be retained for searching the record (as required by law) and a Certificate of No Public Record, or a letter confirming the existence of a confidential marriage will be issued to the applicant. Indicate the number of certified copies you wish and include the correct fee(s) in the form of a personal check, postal or bank money order (International Money Order for out-of-country requests) made payable to the Ventura County Clerk and Recorder. Mail this application with the fee(s) and a self-addressed stamped envelope to:

MARK A. LUNN

Ventura County Clerk and Recorder 800 S. Victoria Ave

Ventura, CA 93009-1260

Website: recorder.countyofventura.org

Telephone number (805) 654-2295 Fax (805) 662-6543

6. Credit card orders may be processed on-line at www.vitalchek.com Additional costs apply for processing orders using a credit card. Please follow the directions on Vitalchek’s website if ordering

using a credit card.

MARRIAGE RECORD

Page 3 of 3

CCR VITAL 08 (Rev 08/2010)