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.