To The Department of State-Passport Vital Records

Section I.  I, (name of birth certificate holder):   __________________________________________  give permission for my parent

(Name of parent requesting):  __________________________________________

to request and receive my birth certificate for me since I have no current valid ID to do it for myself.

 

Certificate holder signature: __________________________     Date: ____________

 

Notary signature: _____________________________    Date: _____________

My commission expires on: ____/_____/ 20___


Note: This must be signed in front of a Notary in addition to any other form.