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Get FL DH 1958 2010-2024

Signature of notary print type or stamp name of notary SEAL Even if personally known to the notary the rules of the Department of Health require the person completing this form to provide a photocopy of valid photo identification. DH Form 1958 August 2010 Obsoletes previous editions 64V-1. AFFIDAVIT TO RELEASE BIRTH CERTIFICATION If you are eligible to receive the birth certificate requested below you may use this form to name another person to receive the birth certificate for you. State of County of My Name is print name. I am eligible by law to receive the birth certificate requested below because I am the check one Child named on the birth certificate and of legal age 18. Parent listed on the child s birth certificate. Legal Guardian of the child named on the birth certificate Documentation required. Legal Representative of the child or parent named on the birth certificate I authorize the Department of Health Office of Vital Statistics to issue the birth certificate of to. child named on birth certificate print name of person to receive birth certificate Required I have attached a photocopy of my valid photo ID type of Identification attached If attorney only bar number required rd NOTE Pursuant to s. 382. 026 Florida Statutes it is a 3 degree felony to obtain and use a Florida birth record fraudulently punishable as set forth in s. 775. 082 s. 775. 083 or s. 775. 084 Florida Statutes. I hereby swear or affirm the above statements are true and correct. signature of person checked above Subscribed and sworn before me this day of 20 by produced as Identification* My Commission Expires. AFFIDAVIT TO RELEASE BIRTH CERTIFICATION If you are eligible to receive the birth certificate requested below you may use this form to name another person to receive the birth certificate for you. State of County of My Name is print name. I am eligible by law to receive the birth certificate requested below because I am the check one Child named on the birth certificate and of legal age 18. State of County of My Name is print name. I am eligible by law to receive the birth certificate requested below because I am the check one Child named on the birth certificate and of legal age 18. Parent listed on the child s birth certificate. Legal Guardian of the child named on the birth certificate Documentation required. Parent listed on the child s birth certificate. Legal Guardian of the child named on the birth certificate Documentation required. Legal Representative of the child or parent named on the birth certificate I authorize the Department of Health Office of Vital Statistics to issue the birth certificate of to. Legal Representative of the child or parent named on the birth certificate I authorize the Department of Health Office of Vital Statistics to issue the birth certificate of to. child named on birth certificate print name of person to receive birth certificate Required I have attached a photocopy of my valid photo ID type of Identification attached If attorney only bar number required rd NOTE Pursuant to s. .

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