The Affidavit of Homeless Status is a State of California Department of Public Health form that the Sacramento County Clerk/Recorder publishes for people who need a certified copy of a birth certificate without paying a fee. It is used by a homeless person, or homeless child or youth, or by someone lawfully entitled to request the record for them, together with a homeless services provider who verifies the status. On FillingPDF you can fill out the form online and download or print the completed PDF; the official PDF is published by the Sacramento County Clerk/Recorder at ccr.saccounty.gov.
Last updated
What is Affidavit of Homeless Status – Sacramento County, CA?
The Affidavit of Homeless Status is the sworn form that verifies a person's homeless status so a county recorder or local registrar can issue a certified record of live birth without a fee, under Health and Safety Code Section 103577.
The printed title is "Affidavit of Homeless Status for Fee Exempt Certified Copy of Birth Certificate." It is a State of California – Health and Human Services Agency, California Department of Public Health form, and the Sacramento County Clerk/Recorder offers it on its page "No Fee Birth Certificate for Homeless Persons." The form states that it must be used for the purpose of requesting a fee-exempt certified copy of a Certificate of Live Birth.
It has two sections. Section I is completed by the person making the request (the "requestor"), who swears or affirms that they are homeless, or that they are lawfully entitled to request the record on behalf of a named homeless child or youth. Section II is completed by an agent of a "homeless services provider," who swears or affirms that the named person is homeless and that the provider meets the statutory definition. "Homeless" has the meaning given in 42 U.S.C. Section 11301 et seq.
The affidavit does not replace the birth record application: fee-exempt requests remain subject to the other requirements of the Application for a Birth Certificate, which the county lists as a separate form.
Who needs to file Affidavit of Homeless Status – Sacramento County, CA?
The main group is people who need a certified copy of a birth certificate, can verify that they are homeless, and want it without a fee. Requests may be made by:
- a homeless person, or homeless child or youth, for themselves; or
- any person lawfully entitled to request a certified record of live birth on behalf of a homeless person, child or youth.
A homeless services provider who knows of the person's homeless status must verify it by completing Section II. The form lists these providers:
- a governmental or nonprofit agency funded by federal, state, county or municipal money to serve homeless persons, or sanctioned by a local homeless continuum of care organization;
- an attorney licensed to practice law in California;
- a local educational agency liaison for homeless children and youth, or a school social worker;
- a human services or public social services provider funded by the State of California for homeless children or youth services, health, mental or behavioral health, substance use disorder, public assistance or employment services;
- a law enforcement officer designated as a liaison to the homeless population by a local police or sheriff's department in the state.
The affidavit is not complete unless both the provider and the requestor sign it. A fee-exempt copy cannot be obtained from the State Registrar.
When to file Affidavit of Homeless Status – Sacramento County, CA
Use the affidavit when you request a fee-exempt certified copy of a birth certificate, because it goes in with that request. Neither the form nor the county's page sets a deadline. Each signer swears or affirms the statement as of "the date listed below" in their section, so the date written beside each signature matters. Complete the provider's section when the provider can verify your status. The form allows one fee-exempt birth record per eligible person, per application.
Documents you need
- Application for a Birth Certificate, from the vital records office of the county where the birth occurred: fee-exempt requests remain subject to the other requirements in that application.
- The completed affidavit with both signatures: the requestor in Section I and the agent of the homeless services provider in Section II. The affidavit is not considered complete without both.
How to fill out Affidavit of Homeless Status – Sacramento County, CA
Read the Information section first
The form asks you to read the Information section before completing the affidavit. It explains eligibility, the one-copy limit and the list of homeless services providers.
Print the requestor's name in Section I
On the line after "I," enter the printed name of the requestor, the person making the request for the certified birth record.
Mark your status
Mark the first option if you are a homeless person, or homeless child or youth. Mark the second if you are lawfully entitled to request the record on behalf of a homeless child or youth, and print that child or youth's name on the line provided.
Sign and date Section I
The requestor signs and writes the date beside Signature of Requestor. The statement is sworn as of that date.
Enter the provider's details in Section II
The homeless services provider's entity name, address, phone number and e-mail go in the lines for Entity Name of Homeless Services Provider Furnishing Verification of Homelessness.
Name the agent and the homeless person
The provider's agent prints their own name after "I," then prints the name of the homeless person or homeless child or youth being verified.
Have the provider's agent sign and date
The agent signs and dates beside Signature of Agent for Provider, confirming the person is homeless and that the provider meets the statutory definition.
Review and download the completed PDF
Check that both sections are complete and both signatures are in place, then download or print the completed PDF from FillingPDF and send it with your birth certificate application as described under How to submit.
How to submit Affidavit of Homeless Status – Sacramento County, CA
Requests for a fee-exempt birth record may be submitted in person, by mail or by fax, according to the Sacramento County Clerk/Recorder's page. The affidavit form is available online and in person at any of the office's locations.
- In person: bring the signed affidavit with your birth certificate application to the vital records office of the county where the birth occurred.
- By mail: send the same package to that office.
- By fax: the county lists fax as an accepted channel; ask the office for its number.
A fee-exempt copy can be issued only by the local registrar or county recorder in the county where the person was born, not by the State Registrar. Applications for a certified copy may be obtained by contacting that county's vital records office. The form and the county page print no mailing address or fax number for this affidavit, so confirm them with the office. FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Submitting the affidavit with only one signature; it is not complete unless both the homeless services provider and the requestor have signed.
- Asking the State Registrar for the fee-exempt copy; it can be obtained only from the local registrar or county recorder in the county where the registrant was born.
- Having someone who is not on the form's list of homeless services providers complete Section II.
- Expecting more than one fee-exempt birth record per eligible person, per application.
- Sending the affidavit alone and skipping the Application for a Birth Certificate; the request is still subject to that application's requirements.
- Leaving the homeless child or youth's printed name blank when you are requesting on behalf of a child or youth.
- Leaving both status options in Section I unmarked, so it is unclear whether you are the homeless person or a person requesting on behalf of a child or youth.
Frequently asked questions
What is the Affidavit of Homeless Status used for?
It verifies that a person is homeless so a local registrar or county recorder can issue a certified copy of a California birth certificate without a fee. The form states that it must be used for requesting a fee-exempt certified copy of a Certificate of Live Birth, under Health and Safety Code Section 103577.
Is the Affidavit of Homeless Status a Sacramento County property tax form?
No. Although the Sacramento County Clerk/Recorder publishes it, it has nothing to do with Sacramento County property tax. It is a vital records form for requesting a fee-exempt certified copy of a birth certificate.
Who has to sign the affidavit?
Two people must sign. The requestor signs Section I, and an agent of a homeless services provider signs Section II. The form and the county's page both say the affidavit is not considered complete unless both have signed.
Who counts as a homeless services provider?
The form lists five types: a funded or sanctioned governmental or nonprofit agency, a California-licensed attorney, a local educational agency liaison or school social worker, a state-funded human services or public social services provider, and a designated law enforcement liaison to the homeless population.
Can someone request the birth certificate for a homeless child?
Yes. A person lawfully entitled to request a certified record of live birth may do so on behalf of a homeless child or youth. In Section I, mark the second option and print the child or youth's name.
Can I get a fee-exempt birth certificate from the State Registrar?
No. A fee-exempt copy can be obtained only from the local registrar or county recorder office in the county where the registrant was born, not from the State Registrar.
How many fee-exempt copies can I get?
One. Each eligible person may receive only one fee-exempt birth record, per application. The request is also still subject to the other requirements in the Application for a Birth Certificate.
Where do I submit the affidavit?
Submit it with your birth certificate application to the vital records office in the county where the birth occurred. The Sacramento County Clerk/Recorder says requests may be made in person, by mail or by fax.
Can I fill out the Affidavit of Homeless Status online?
You can fill out the PDF online on FillingPDF and download or print it, but both signatures are still needed. FillingPDF is an independent service: it does not file the affidavit, and you submit it through the county's channels.
Ready to fill out Affidavit of Homeless Status – Sacramento County, CA?
Fill out Affidavit of Homeless Status – Sacramento County, CA now