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Authorization Form

This document provides instructions for identity verification for an order with Los Angeles County Registrar/Recorder. It states that a notarized Sworn Statement and Certificate of Acknowledgment form must be completed and submitted before the order can be processed. It includes a sample form and outlines two options for submitting it - uploading a scanned copy or faxing it. The instructions emphasize ensuring all requested information is legible on the submitted form.

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Donna Ontiveros
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84 views2 pages

Authorization Form

This document provides instructions for identity verification for an order with Los Angeles County Registrar/Recorder. It states that a notarized Sworn Statement and Certificate of Acknowledgment form must be completed and submitted before the order can be processed. It includes a sample form and outlines two options for submitting it - uploading a scanned copy or faxing it. The instructions emphasize ensuring all requested information is legible on the submitted form.

Uploaded by

Donna Ontiveros
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Identity Verification Instructions

LOS ANGELES COUNTY REGISTRAR/RECORDER


Order Number: 122472169 PIN: 135796

Thank you for your recent order. Please be advised that Los Angeles County Registrar/Recorder requires a notarized Sworn
Statement and Certificate of Acknowledgment before your order can be processed. Instructions are provided below.

Step 1: Prepare Your Documentation

If you do not follow these instructions, it could delay the processing of your
order.
1. Print the attached Sworn Statement/Certificate of Acknowledgment form. No other forms will
be accepted.
2. Verify the information on the form to be sure it is correct.
3. Sign and date the form in the presence of a Notary Public.
4. The Notary's stamp/seal must be legible.
5. The Notary's commission date must be legible and cannot be expired.
6. The date of your signature on the form must match the Notary's signature date.

Step 2: Submit Your Documentation

OPTION 1: Upload of a Scanned or Photographed Image


1. Scan or photograph the completed form.
2. Be sure all of the information requested is visible on the image.
3. Ensure the scanned or photographed image is saved to one or more files on your computer.
Only the following file formats can be accepted: bmp, gif, jpg or jpeg, tiff, and pdf.
4. Visit the 'Manage My Order' page on VitalChek.com:
https://www.vitalchek.com/order_status_signon.aspx
5. Enter your order number: 122472169 and PIN: 135796
6. Select 'Upload Documents Now' under #2 on the 'Completing Your Order' page
7. Select the scanned image file(s) that you wish to upload
8. Attach the scanned image file(s) to your order

OPTION 2: Fax
1. Make sure all photocopies are legible.
2. Be sure all the information requested is visible on the image.
3. Fax the Identity Verification Form and any other documentation to (866)-283-7407.

1
122472169 Vital Records Authorization Form
Los Angeles County Registrar/Recorder
P.O. Box 1703
Brentwood, TN 37024
VitalChek Order Number/PIN: 122472169 / 135796

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 birth, death or marriage record of the following
individual(s).
Name of Person Listed on Certificate Relationship to Person Listed on Certificate

Birth Authorized Copy : Alyssa Dragna Legal Guardian

Sworn this ______


day of ________, 20____ at __________________________
, _______.
(Day) (Month) (City) (State)

____________________________________
Signature

Note: If submitting your order online or by fax and requesting an Authorized Birth, Death or Marriage Certificate, you must have
your Sworn Statement notarized using the Certificate of Acknowledgment below.
-------------------------------------------------------------------------------------------------------------------------------------------------------------------

A notary public or other officer completing this certificate verifies only the identity of the individual who
signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that
document.

Certificate of Acknowledgment
State of )
) ss
County of )

On _____________, before me, , NOTARY PUBLIC , personally


(insert name and title of officer)
appeared, , who proved to me on the basis of
(insert name of person signing)

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 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


(NOTARY SEAL)
_______________________________________
Notary Signature

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