Vital Records Authorization Form
San Francisco County Asssor-Recorder (Phil Ting)
#1 Dr. Carlton B. Goodlett Place
City Hall Rm# 190
San Francisco, CA 94102
Instructions:
VitalChek Order Number: 28130647
1. Verify that all information below is correct.
2. Print and complete this form.
- To receive a Certified Copy, you will need to complete both ctions below, Sworn Statement & Certificate of Acknowledgment.
- To receive an Informational Copy, you only need to complete the Sworn Statement.
3. Sign and date the form.
4. Fax the signed form to (415)-554-4803.
Sworn Statement
I, __________________________________ swear/affirm under penalty of perjury under the laws of the State
of California, that I am an authorized person, as defined in the California Health and Safety Code Section
103526(c) , and am eligible to receive a certified copy of the marriage record of the following individual(s).
Name of Person Listed on Certificate Relationship to Person Listed on Certificate
Public Marriage Certificate : Yun Lin Self
, _______.
Sworn this______d ay of________, 20____at__________________________
(Day)(Month)(City)(State)
____________________________________
Signature
- To receive a Certified Copy, you will need to complete both ctions, Sworn Statement & Certificate of Acknowledgment.
- To receive an Informational Copy, you only need to complete the Sworn Statement above.
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Certificate of Acknowledgment
State of)
) ss
County of)
On _____________, before me, , NOTARY PUBLIC , personally
(inrt name and title of officer)
appeared,, who proved to me on the basis of
(inrt name of person signing)
satisfactory evidence to be the person(s) who 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
