Human Services Form Vs111 – Fill Out and Use This PDF

The Human Services Vs111 form is an essential document handled by the California Department of Public Health, aimed at individuals seeking to obtain a certified copy of a birth record. It's designed to streamline the process while also safeguarding against identity theft by ensuring only authorized persons can request and receive these sensitive documents. Depending on the applicant's relationship to the registrant and the type of copy requested, the process may require a notarized sworn statement. For those looking to request a certified copy of a birth record, you can kickstart the process by clicking the button below.

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Human Services Form Vs111 PDF Details

In the State of California, the procurement of certified birth records is meticulously governed to protect individuals' privacy and prevent identity theft. The Human Services VS111 form, issued by the California Department of Public Health, is central to this process, stipulating a structured protocol for requesting certified copies of birth records. This application form is designed with stringent measures, elucidated by California law (Health and Safety Code Section 103526), which strictly limits the issuance of certified copies to individuals explicitly listed on the application to thwart unauthorized access. By categorizing eligible relationships and necessitating a sworn, possibly notarized statement, it ensures that only those with a legitimate claim can obtain these records—whether for legal, personal, or governmental needs. Furthermore, the form accommodates requests for Certified Informational Copies, which, while containing the same data (minus sensitive information) as the certified copies, bear a legend explicitly stating their incapacity to serve as identity documents. Alongside outlining the application steps, including fees and mailing instructions, it integrates precautions against cash transactions, reinforcing the safety and integrity of the application process. This careful orchestration of requirements highlights the delicate balance between public access to essential documents and the protection of individual privacy and security within the administrative framework of California’s public health records management.

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Form Name	Human Services Form Vs111
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	vs111 form california, vs 111 form california, vs111, vs 111

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State of California – Health and Human Services Agency

California Department of Public Health

APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD

PLEASE READ THE INSTRUCTIONS ON PAGE 2 BEFORE COMPLETING THIS APPLICATION

As part of statewide efforts to prevent identity theft, California law (Health and Safety Code Section 103526) permits only authorized individuals as listed on the application to receive certified copies of birth records. All others will be issued Certified Informational Copies marked with the legend, Informational, Not A

Valid Document to Establish Identity.

Please indicate the type of certified copy you are requesting:



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 by selecting 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.)

NOTE: Both documents are certified copies of the original document on file with our office. With the exception of the legend and redaction of signatures and Social Security Number, the documents contain the same information.

Fee: $20 per copy (payable to CDPH Vital Records). PLEASE SUBMIT CHECK OR MONEY ORDER – DO NOT SEND CASH

(CDPH cannot be held responsible for fees paid in cash that are lost, misdirected, or undelivered).

To receive a Certified Copy I am:

		The registrant (person listed on the certificate) or a parent or legal guardian of the registrant. (Legal guardian must provide documentation.)

		A party entitled to receive the record as a result of a court order or an attorney or a licensed adoption agency seeking the birth
		record in order to comply with the requirements of Section 3140 or 7603 of the Family Code. (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 registra t’s estate, o a	pe so o age	e po e ed statute o appoi ted by a court
	
		to act on ehalf of the egist a t o the egist a t’s estate.

		Appointed rights in a power of attorney, o a e e uto of the egist a	t’s estate. (Please include a copy of the power of attorney, or
		supporting documentation identifying you as executor.)

PLEASE ATTACH CHECK HERE

	APPLICANT INFORMATION (PLEASE PRINT OR TYPE)			Today’s Date:
	Agency Name (if applicable)			Agency Case Number	Inmate ID Number

	Print Name of Applicant			Signature of Applicant	Purpose of Request

	Mailing Address – Number, Street			Amount Enclosed – DO NOT SEND CASH		Number of Copies
				$ _______ Check $ ______ Money Order

	City			Name of Person Receiving Copies, if Different from Applicant

	State/Province		ZIP Code	Mailing Address for Copies, if Different from Applicant

	Daytime Telephone (include area code)		Country	City		State	ZIP Code
(		)

BIRTH RECORD INFORMATION (PLEASE PRINT OR TYPE) Adopted:

No

Yes (If Yes, see #4 on Page 2)

Complete the information below as shown on the birth record, to the best of your knowledge.

FIRST Name	MIDDLE Name	LAST Name

City of Birth (must be in California)		County of Birth

Date of Birth – MM/DD/CCYY (If unknown, enter approximate date of birth)		Sex
			___	Female	___	Male

Father/Parent FIRST Name	MIDDLE Name	LAST Name (Before Marriage/Domestic Partnership)

Mother/Parent FIRST Name	MIDDLE Name	LAST Name (Before Marriage/Domestic Partnership)
	MIDDLE Name	LAST Name (Before Marriage/Domestic Partnership)

BIRTH

VS 111 (01/13)

Page 1 of 3

INFORMATION:

Birth records have been maintained in the California Department of Public Health Vital Records since July 1, 1905.

The name required on Vital Records (see Items 1C, 6C, 7C, 9C, and 12C) is the name given at birth, or a name received through adoption, court-ordered name change, or naturalization. AKAs (Also Known As) and assumed names cannot be entered as the legal name on the birth record.

INSTRUCTIONS:

1.ONLY individuals who are authorized by Health and Safety Code Section 103526 can obtain a Certified Copy of a birth record

to establish identity of the registrant (person listed on the certificate). (Page 1 identifies the individuals who are authorized

to ake the	e	uest.) All othe s	a e ei e a Ce tified I fo atio al Cop hi h ill e a ked, I fo atio al, Not a
Valid Do u	e	t to Esta lish Ide	tit .

Confidential Information on Birth Record: some individuals have special needs for a birth certificate that contains the confidential information provided at the time the birth record was prepared. This confidential information may be used to establish ethnicity, to provide health background, or for other personal reasons. For information on how to obtain a birth certificate containing the confidential information, please refer to the Birth Record section of our website at: www.cdph.ca.gov. Only specific individuals may obtain confidential copies.

2.Complete a separate application for each birth record requested.

3.Complete the Applicant Information section on Page 1 and provide your signature where indicated. In the Birth Record Information section, provide all the information you have available to identify the birth record. If the information you furnish is incomplete or inaccurate, we may not be able to locate the record.

4.If the registrant has been adopted, make the request in the adopted name. If the registrant was born outside the United

States and re-adopted i Califo ia, a k the Yes o a d o plete the appli atio ith the adopted i fo atio . (If you

are requesting a copy of the original birth certificate, you must provide a court order releasing the original sealed record.)

5.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 birth record and identify their relationship to the registrant – the relationship must be one of those identified on Page 1.

∙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.

∙You do not have to provide a Sworn Statement if you are requesting a Certified Informational Copy of the birth record.

6.Submit $20 for each copy requested. If no birth record is found, the $20 fee will be retained for searching for the record

(as required by law) and a Certificate of No Public Record will be issued to the applicant. Indicate the number of copies you want and include the correct fee(s) in the form of a personal check or postal or bank money order (International Money Order for out-of-country requests) made payable to CDPH Vital Records. PLEASE SUBMIT CHECK OR MONEY ORDER – DO NOT SEND CASH (CDPH cannot be held responsible for fees paid in cash that are lost, misdirected, or undelivered).

7.Mail completed applications with the fee(s) to:

California Department of Public Health

Vital Records – MS 5103

P.O. Box 997410

Sacramento, CA 95899-7410

(916) 445-2684

BIRTH

Page 2 of 3

VS 111 (01/13)

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):

Name of Person Listed on Certificate

Applicant’s Relationship to 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 CDPH 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 Acknowledgment 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 ______________________________,

(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 OF NOTARY PUBLIC

Page 3 of 3

VS 111 (01/13)

			CALIFORNIA COUNTY RECORDERS
Alameda…………………	1108		Madison Street, 1st Floor, Oakland, C 94607, (510) 272-6363
Alpine…………………...	P.O. Box 217, Markleeville, CA 96120-0217, (530) 694-2286
Amador………………….	810	Court Street, Jackson, CA 95642 Attn: Tico, (209) 223-6468
Butte…………………….	25 County Center Drive, Administration Building., Oroville, CA 95965, (530) 538-7691
Calaveras………………..	Government Center, 891 Mountain Ranch Road, San Andreas, CA 95249, (209) 754-6372
Colusa…………………...	546	Jay Street, Colusa, CA 95932, (530) 458-0500
Contra Costa…………….	555	Escobar Street, Martinez, CA 94553, (925) 335-7900
Del Norte………………..	981	H Street, Suite 160, Crescent City, CA 95531, (707) 464-7216
El Dorado……………….	360	Fair Lane, Placerville, CA 95667, (530) 621-5490
Fresno…………………...	2281		Tulare Street, Room 303, or P.O. Box 766, Fresno, CA 93712, (559) 488-3476
Glenn……………………	526	West Sycamore Street, Courthouse, Willows, CA 95988, (530) 934-6412
Humboldt……………….	825	5th Street, Fifth Floor, Eureka, CA 95501, (707) 445-7382
Imperial…………………	940	West Main Street, Room 206, El Centro, CA 92243, (760) 482-4272
Inyo……………………..	Courthouse, 168 N. Edwards Street, Independence, CA 93526, (760) 878-0222
Kern…………………….	1655		Chester Avenue, Bakersfield, CA 93301, (661) 868-6449
Kings……………………	Government Center, 1400 W. Lacey Blvd., Hanford, CA 93230, (559) 582-3211, X 2470
Lake…………………….	Courthouse, 255 North Forbes Street, Lakeport, CA 95453, (707) 263-2293
Lassen…………………..	Courthouse, 220 S. Lassen Street, Suite 5, Susanville, CA 96130, (530) 251-8234
Los Angeles…………….	12400 Imperial Highway, Room 1002, Norwalk, CA 90650, (562) 462-2137 or 2101 or 2102
Madera………………….	200	West 4th Street, Madera, CA 93637, (559) 675-7724
Marin……………………	3501		Civic Center Drive, Courthouse, Room 232, San Rafael, CA 94903, (415) 499-6092
Mariposa………………..	4982		10th Street, P.O. Box 35, Mariposa, CA 95338, (209) 966-5719
Mendocino……………...	501	Low Gap Road, #1020, Ukiah, CA 95482, (707) 463-4376
Merced………………….	2222		M Street, Merced, CA 95340, (209) 385-7627
Modoc…………………..	204	S. Court Street, Room 107, Alturas, CA 96101-4020, (530) 233-6205
Mono……………………	74 School Street, Annex I, P.O. Box 237, Bridgeport, CA 93517-0237, (760) 932-5535
Monterey………………..	168	West Alisal Street, First Floor, P.O. Box 29, Salinas, CA 93902-0029, (831) 755-5041
Napa…………………….	900	Coombs Street, Room 116, P.O. Box 298, Napa, CA 94559-0298, (707) 253-4246
Nevada………………….	950	Maidu Avenue, Nevada City, CA 95959, (530) 265-1221
Orange………………….	12 Civic Center Plaza, Room 101 or P.O. Box 238, Santa Ana, CA 92702-0238, (714) 834-2500
Placer…………………...	2954		Richardson Drive, Auburn, CA 95603, (530) 886-5600
Plumas………………….	520	Main Street, Room 102, Quincy, CA 95971, (530) 283-6218
Riverside……………….	2724		Gateway Drive, or P.O. Box 751, Riverside, CA 92502-0751, (951) 486-7000
Sacramento……………..	600	8th Street, or P.O. Box 839, Sacramento, CA 95812-0839, (916) 874-6334
San Benito………………	County Courthouse, 440 5th Street, Room 206, Hollister, CA 95023-3896, (831) 636-4029
San Bernardino…………	222	W. Hospitality Lane, First Floor, San Bernardino, CA 92415-0022, (855) 732-2575
San Diego………………	1600		Pacific Highway, Room 260, or P.O. Box 12150, San Diego, CA 92112-4750, (619) 237-0502
San Francisco…………..	One Dr. Carlton B. Goodlett Place, City Hall Room 190, San Francisco, CA 94102, (415) 554-2700**
San Francisco Health Dept.	101 Grove Street, Room 105, San Francisco, CA 94102, (415) 554-5596, (415) 554-4950*
San Joaquin…………….	44 N. San Joaquin St., Ste 260, or P.O. Box 1968, Stockton, CA 95201-1968, (209) 468-8075
San Luis Obispo………..	1055		Monterey Street, D120, San Luis Obispo, CA 93408, (805) 781-5080
San Mateo………………	Vital Records, 1st Floor, 555 County Center Dr., Redwood City, CA 94063-1665, (650) 363-4713
Santa Barbara…………..	1101		Anacapa Street, P.O. Box 159, Santa Barbara, CA 93102-0159, (805) 568-2250
Santa Clara……………..	County Government Center, East Wing, 1st Flr, 70 W. Hedding St., San Jose, CA 95110, (408) 299-5669
Santa Cruz……………...	701	Ocean Street, Room 230, Santa Cruz, CA 95060, (831) 454-3222
Shasta…………………...	1450		Court Street, Suite 208, Redding, CA 96001, (530) 225-5678
Sierra……………………	P.O. Drawer D., Downieville, CA 95936, (530) 289-3295
Siskiyou ………………..	311	4th Street, Room 108, Yreka, CA 96098, (530) 842-8065
Solano………………….	675	Texas Street, Suite 2700, Fairfield, CA 94533, (707) 784-6294
Sonoma…………………	585	Fiscal Drive, Room 103F, or P.O. Box 1709, Santa Rosa, CA 95402, (707) 565-2645
Stanislaus………………	1021		I Street, Suite 101, or P.O. Box 1670, Modesto, CA 95353, (209) 525-5251
Sutter…………………..	433	Second Street, Yuba City, 95991, (530) 822-7134
Tehama…………………	633	Washington Street, Room 11 or P.O. Box 250, Red Bluff, CA 96080, (530) 527-3350
Trinity………………….	11 Court Street, P.O. Box 1215, Weaverville, CA 96093, (530) 623-1215
Tulare…………………..	County Civic Center, 221 S. Mooney Blvd., Room 103, Visalia, CA 93291-4593, (559) 636-5050
Tuolumne………………	2 South Green Street, Sonora, CA 95370, (209) 533-5531
Ventura…………………	800	South Victoria Avenue, LN 1260, Ventura, CA 93009, (805) 654-2295 or (805) 654-3666
Yolo……………………	625	Court Street, Room B01, or P.O. Box 1130, Woodland, CA 95776-1130, (530) 666-8130
Yuba……………………	915	8th Street, Suite 107, Marysville, CA 95901, (530) 749-7851

* Public Marriages

** Birth and Death Certificates

Rev. 01/01/13

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2. After the previous section is complete, you're ready to put in the needed details in Agency Name if applicable, Agency Case Number, Inmate ID Number, Print Name of Applicant, Signature of Applicant, Purpose of Request, Mailing Address Number Street, City, Amount Enclosed DO NOT SEND CASH, Number of Copies, Check Money Order Name of, StateProvince, ZIP Code, Mailing Address for Copies if, and Daytime Telephone include area allowing you to go further.

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4. This specific part comes next with these particular fields to complete: I declare under penalty of, Applicants Printed Name, that I am an authorized person as, certified copy of the birth death, Name of Person Listed on, Applicants Relationship to Person, Must Be a Relationship Listed on, The remaining information must be, and Subscribed to this day of at.

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5. The very last notch to conclude this document is essential. You'll want to fill out the mandatory fields, consisting of Subscribed to this day of at, Month, Day, State, City, Applicants Signature, Note If submitting your order by, CERTIFICATE OF ACKNOWLEDGMENT, State of County of, and On before me personally appeared, before submitting. In any other case, it may generate a flawed and probably incorrect document!

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