PART I. ENTER NAME, DATE AND PLACE OF BIRTH/DEATH, AND NAMES OF PARENTS AS INFORMATION APPEARS ON
BIRTH/DEATH &(57,),&$7(
FULL NAME OF PERSON ON RECORD
DATE OF BIRTH/DEATH
PLACE OF BIRTH/DEATH (City or County)
SEX
FULL NAME OF PARENT 1
FULL NAME OF PARENT 2
NAME AND RELATIONSHIP TO PERSON ON RECORD
AFFIDAVIT OF PERSONAL KN
O
WLEDGE
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.
MAIL THIS SWORN STATEMENT, APPLICATION, PAYMENT, AND A PHOTOCOPY OF YOUR VALID PHOTO ID TO:
Corpus Christi Vital Records
1702 Horne Road Room 21
Corpus Christi, Texas 78416
(APPLICATIONS WITHOUT THE SWORN STATEMENT AND PHOTO ID WILL NOT BE PROCESSED)
VS-142.3(A) Rev. 09/2015
Page 2 of 2
NOTARIZED PROOF OF IDENTIFICATION
(Seal)
TYPE
AND NUMBER OF ID ACCEPTED WHEN NOTARIZED
STATE OF _____________________
COUNTY OF _____________________
Before me on this day appeared ____________________________BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB___________BB
QRZUHVLGLQJDWBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB__________________BB
who is related WRWKHSHUVRQQDPHGRQ3DUW,DVBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB___BBDQGZKRRQRDWKGHSRVHVDQG
VD\VWKDW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)