Instructions to apply for an INFORMATIONAL copy of a Birth certificate 1. Complete the form below for each Birth certificate you are requesting. 2. Send the form with a check or money order for $25.00 for each certificate to: Inyo County Recorder PO Box F Independence, CA 93526

Information of Birth record Number of copies requested @ $25.00 each _______ Name on certificate – First

Middle

Last

Date of birth

Place of birth – City or Town Place of birth - County

Father’s name

Sex

Mother’s maiden name

Information of person requesting certificate Printed name of person completing Date application

Telephone number

Address – Number, Street or P. O. Box

City

State

Zip code

Mailing address for copies if different from above

City

State

Zip code

Signature of applicant