ESTABLISH RECORD OF UNRECORDED BIRTH BY NON-PARENT
State of: ___________________
County of: _________________
I, _____________________________________ (full
name), being sworn, declare that:
1. The full
name of the person whose birth is being registered is __________________
________________, a ___________ (male/female).
person whose birth is being registered was born on ____________________ (month
& day) ________ (year), at ________________________________________
The full name of the father whose child's birth is
being registered is _____________
________________________. The last known residence of the father is ____________
4. The full
maiden name of the mother whose child's birth is being registered is
____________________________________________, and her last known
residence is ______________________________________________________ (address).
5. I have
firsthand and personal knowledge of the birth of the person whose birth is
being registered as follows: ______________________________________________.
6. I am
__________ (_____) years of age, and I am related to the person whose birth is
being registered as follows: __________________ (exact relationship). My address is
I declare under a penalty of perjury that the
foregoing is true and correct.
Sworn before me on this ____ day of
___________________ (month), _________ (year).
My Commission Expires: _______________