Form Phs520F PDF Details

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QuestionAnswer
Form NameForm Phs520F
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesLouisiana, form of birth certificate, WILLFULLY, FALSE

Form Preview Example

PHS520F(Rev. 6/00)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

________________________________________________________________________________________________

NAME AT BIRTH (FIRST, MIDDLE, LAST)

 

 

 

__________________________________________________

___________________________________________

DATE OF BIRTH

 

 

SEX

 

 

________________________________________________________________________________________________

CITY OF BIRTH

 

 

PARISH OF BIRTH

 

________________________________________________________________________________________________

FATHER’S NAME

 

 

 

 

 

________________________________________________________________________________________________

MOTHER’S MAIDEN NAME"(BEFORE MARRIAGE)

 

 

 

HOW ARE YOU RELATED TO THE PERSON WHOSE RECORDS YOU ARE REQUESTING? (Check one:)

______ Self

______Mother/Father

______Child

______Grandparent

______Grandchild

______ Current Spouse

______Sister/Brother

 

______Legal Guardian (

PRINT YOUR ADDRESS:

 

 

 

 

 

Name________________________________________________________

 

Street or

 

 

 

 

 

 

Route No.____________________________________________________

Number of

 

City

 

 

 

 

Copies Requested: _____________________

and State_____________________________________________________

 

 

Home

 

Office

ZIP CODE

 

Total Fees Due

$____________________

Phone No.___________________ Phone No.___________________

I AM AWARE THAT ANY PERSON WHO WILLFULLY AND KNOWINGLY MAKES ANY FALSE STATEMENT IN AN APPLICATION FOR A CERTIFIED COPY OF A VITAL RECORD IS SUBJECT UPON CONVICTION TO A FINE OF NOT MORE THAN $10,000 OR IMPRISONMENT OF MORE THAN FIVE YEARS OR BOTH.

 

Signature of Applicant________________________________________________________________

 

 

*Please note:

Birth records over !"#$% and Death records over &!"#$% are obtained by writing the Louisiana State Archives, P.O. Box

 

94125, Baton Rouge, LA 70804"9125. Please make check PAYABLE TO: Secretary of State

 

 

''''''''''''''''''''''''''''

NOTES:

((

 

Computer:

_______________ ___________

Certificate #

_____________________________

Referred to State

 

Vital Records:

_____________________________

 

Date