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Family Member Authorization to RequestCity of College Station Authorization for Qualified Applicant to Request Birth Certificate Instructions: 1.Please have one of the parents fill out this form and have their signature notarized. 2.The parent MUST attach a copy of his/her valid driver’s license. 3.Once this form is completed in its entirety, the qualified authorized applicant will need to fill out an application for the birth certificate. 4.The authorized applicant will then need to provide his/her valid driver’s license. If you have any questions, please contact the Vital Records Office at (979)764-5016. I _______________________ grant permission to __________________________________, my to request a certified copy of (my/son/daughter), ,birth certificate. My/ My son's/My daughter's date of birth is _____/_____/________. (MM/DD/YYYY) _________________________________Signature of Parent/Person Named on Record _____________ Date IMPORTANT: Arrangements must be made with the Local Rgistrars Office prior to requesting a birth certificate on behalf of a family member in order for this release form to be accepted. (Parent/Person Named on Birth Record)(First & Last Name of Person Requesting Birth Record) (Person Named on Birth Record) (Relationship to mother/father)(Circle one) (Circle one) WARNING: IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT ON THIS FORM OR FOR SIGNING A FORM WHICH CONTAINS A FALSE STATEMENT IS 2 TO 10 YEARS IMPRISONMENT AND A FINE OF UP TO $10,000. (HEALTH AND SAFETY CODE, CHAPTER 195, SEC. 195.003) PART I. ENTER THE REGISTRANT'S NAME, DATE AND PLACE OF BIRTH/DEATH, AND SEX. FULL NAME OF PERSON ON RECORD DATE OF BIRTH/DEATH PLACE OF BIRTH/DEATH (City or County) SEX NAME AND RELATIONSHIP TO PERSON ON RECORD AFFIDAVIT OF PERSONAL KNOWLEDGE PART III. THIS SECTION MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC. Signature of Notary Public Commission Expires Typed or Printed Name Street Address City, State and Zip PART II. ENTER RELATIONSHIP TO PERSON ON RECORD AND THE TYPE OF ID USED. SUBMIT THIS SWORN STATEMENT, APPLICATION, PAYMENT, AND A PHOTOCOPY OF YOUR VALID PHOTO ID TO: CITY OF COLLEGE STATION LOCAL REGISTRAR'S OFFICE Mailing Address: P.O. Box 9960 College Station, Texas 77842 (APPLICATIONS WITHOUT THE SWORN STATEMENT AND PHOTO ID WILL NOT BE PROCESSED) VS-142.3(A) Rev. 09/2015 / Form No.: D-02-83 (Rev. 02/2019) NOTARIZED PROOF OF IDENTIFICATION (Seal) TYPE AND NUMBER OF ID ACCEPTED WHEN NOTARIZED STATE OF _____________________ COUNTY OF _____________________ Before me on this day appeared _____________________________________________________________________________________________ now residing at __________________________________________________________________________________________________________, who is related to the person named on Part I as ________________________________________________________ and who on oath deposes and says that the contents of this affidavit are true and correct. Signature ____________________________________________________________ Sworn to and subscribed before me, this ________ day of ______________________, 20 ______. (Name) (Address) (City) (State) (Relationship) WARNING: IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT ON THIS FORM OR FOR SIGNING A FORM WHICH CONTAINS A FALSE STATEMENT IS 2 TO 10 YEARS IMPRISONMENT AND A FINE OF UP TO $10,000. (HEALTH AND SAFETY CODE, CHAPTER 195, SEC. 195.003) Office Address: 1101 Texas Avenue College Station, Texas 77840