Fillable BIRTH CERTIFICATE APPLICATION (Revize)

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BIRTH CERTIFICATE APPLICATION (Revize)

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66 Montgomery County Clerk
Mark Turnbull
BIRTH CERTIFICATE APPLICATION
PLEASE TYPE OR PRINT. APPLICATION MUST BE ORIGINAL (INCLUDING
SIGNATURE). NO CROSS OUT OR WHITE OUT WILL BE ACCEPTED. INCLUDE A
PHOTOCOPY OF YOUR VALID I.D. WHEN SENDING IN THE REQUEST BY MAIL.
STEP 1: YOUR INFORMATION AND MAILING ADDRESS (PLEASE PRINT)
Your Name: (first, middle, last name, suffix):
Street Address:
City:
State:
Zip:
Email Address:
Daytime Phone Number
Your relationship to the person named on the certificate:
Self/Parent
Other (specify):
Reason for request:
Newborn
Travel/Passport
Records
School
Insurance
Other:
I authorize mailing to the address below, if mailing to address other than address listed above:
Name: (first, middle, last name, suffix):
Street Address:
City:
State:
Zip:
STEP 2: INFORMATION FOR THE PERSON NAMED ON THE BIRTH CERTIFICATE (PLEASE PRINT)
Full Name on Certificate
(First, Middle, Last Name, Suffix):
Date of Birth:
Place of Birth:
City:
County:
State: TEXAS ONLY
Parent 1: First, Middle, Last name prior to first marriage (maiden name)
Parent 2: First, Middle, Last name prior to first marriage (maiden name)
STEP 3: COST & FEES (FEES NON-REFUNDABLE)
Select Certificate Type
QTY
Price/Each
Total
CASH, CHECK OR
MONEY ORDER
PLEASE
DO NOT
MAIL CASH
Long Form Certificate (Montgomery County only)
x $23.00
$
Short Form Certificate
x $23.00
$
Military Personnel with current deployment orders
----------EXEMPT----------
I wish to make a voluntary contribution of $5.00 to promote healthy early childhood by supporting the Texas Home Visitation
Program administered by the Office of Early Childhood Coordination of Health and Human Services.
$ 5.00
TOTAL DUE:
$
STEP 4: ACKNOWLEDGMENT – If you are submitting the application by mail, you must have it notarized before mailing it in.
STATE OF Texas
COUNTY of ___________________________________________
(seal
)
This instrument was acknowledged before me on
(date)
By:
(name of person acknowledging)
By:
Notary Public or Deputy Clerk
WARNING: IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY
MAKING A FALSE STATEMENT ON THIS FORM OR 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.)
STEP 5: SIGN
Signature of Applicant:
Date Signed:
Printed Name:
OFFICE USE ONLY
Cash
Check
Money Order
AMOUNT:
$
Date:
Birth Certificate Number:
Document Control Number:
This is a fillable form. You must have it notarized if you are applying by mail.
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BIRTH CERTIFICATE APPLICATION (Revize)

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Completed 26 August 2021

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