The Affidavit of Homeless Status for Fee Exempt Certified Copy of Birth Certificate is the California Department of Public Health form that lets a homeless person, or a homeless child or youth, request a certified birth record without a fee. It is completed in two parts: the requestor signs Section I, and a homeless services provider verifies the status in Section II. The Ventura County Clerk-Recorder publishes the PDF. On this page you can fill out the form online on FillingPDF and download or print the completed PDF.
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What is Affidavit of Homeless Status for Fee Exempt Certified Copy of Birth Certificate?
The Affidavit of Homeless Status for Fee Exempt Certified Copy of Birth Certificate is a California Department of Public Health form that verifies a person's homeless status so a local registrar or county recorder can issue a certified birth record without a fee.
The form rests on California Health and Safety Code Section 103577. It says each local registrar or county recorder shall, without a fee, issue a certified record of live birth to any person who can verify his or her status as a homeless person or a homeless child or youth. The affidavit must be used for the purpose of requesting a fee exempt certified copy of a Certificate of Live Birth. "Homeless person" and "homeless child or youth" have the meaning given in 42 U.S.C. Section 11301 et seq.
The affidavit has two sections. In Section I the requestor swears or affirms that he or she is homeless, or is lawfully entitled to request the record for a named homeless child or youth. In Section II a homeless services provider swears or affirms that the named person is homeless and that the provider meets the definition in Section 103577.
The affidavit does not replace the birth record application. Fee exempt requests remain subject to the other requirements of the application for obtaining copies of birth records. The Ventura County Clerk-Recorder hosts this PDF among its County Recorder forms.
Who needs to file Affidavit of Homeless Status for Fee Exempt Certified Copy of Birth Certificate?
A homeless person, or a homeless child or youth, who can verify that status uses this affidavit to request a fee exempt certified copy of a birth certificate. The request may be made on behalf of themselves, or by any person lawfully entitled to request a certified record of live birth on behalf of a homeless child or youth.
A homeless services provider who has knowledge of the person's status must provide the verification by completing Section II. The form lists who qualifies as a provider:
- a governmental or nonprofit agency receiving federal, state, county or municipal funding to serve homeless people, 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, 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.
Each eligible person may receive only one fee exempt birth record per application. A fee exempt copy cannot be obtained from the State Registrar.
When to file Affidavit of Homeless Status for Fee Exempt Certified Copy of Birth Certificate
Complete the affidavit when you request a fee exempt certified copy of a birth record, because the request is made with it. The form sets no separate deadline. Both the requestor and the provider swear or affirm their statements as of the date each writes next to his or her signature, so sign and date at the time you make the request. The affidavit is not considered complete until both the homeless services provider and the person making the request have signed.
Documents you need
- The application for a certified copy of a birth record, obtained from the vital records office in the county where the birth occurred; fee exempt requests remain subject to its other requirements.
How to fill out Affidavit of Homeless Status for Fee Exempt Certified Copy of Birth Certificate
Read the information section first
Page 1 explains who may request a fee exempt copy and lists the homeless services providers who can verify status. The form tells you to read it before completing the affidavit.
Enter the requestor's printed name
In Section I, print your name on the line after "I,". This section is completed by the person making the request for the certified birth record.
Check the box that describes you
Mark the first box if you are a homeless person or homeless child or youth. Mark the second box if you are lawfully entitled to request the record for a homeless child or youth, and print that child's or youth's name on the line provided.
Sign and date Section I
Sign on the Signature of Requestor line and enter the date. The statement is sworn or affirmed as of that date.
Enter the provider's entity details
In Section II, enter the entity name of the homeless services provider, its address, phone number and e-mail.
Print the provider agent's name
On the line after "I," the agent for the provider prints his or her name. The provider must meet the definition of a homeless services provider listed on the form.
Name the person being verified
Print the name of the homeless person or homeless child or youth whose status the provider is verifying.
Sign and date Section II
The agent for the provider signs and dates the Signature of Agent for Provider line. Without this signature and the requestor's, the affidavit is not complete.
Review and download the completed PDF
Check both sections, the names and both signatures, then download or print the completed PDF from FillingPDF and give it to the county office with the birth record application.
How to submit Affidavit of Homeless Status for Fee Exempt Certified Copy of Birth Certificate
The form names the offices that handle the request: the local registrar or the county recorder office in the county where the registrant was born. It says a fee exempt copy cannot be obtained from the State Registrar.
- Where to request: the vital records office, local registrar or county recorder office in the county of birth. The form says the application for a certified copy of a birth record is obtained from that office.
- What to send or bring: the signed affidavit with the birth record application. Fee exempt requests are still subject to the other requirements of that application.
- Signatures: both the requestor and the homeless services provider must sign, or the affidavit is not complete.
The form prints no mailing address, portal or appointment rule, so contact the county office for how it accepts the request. The Ventura County Clerk-Recorder posts the PDF at https://clerkrecorder.venturacounty.gov/county-recorder/forms/. 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 person making the request have signed.
- Asking the State Registrar for the fee exempt copy; the form says it can be obtained only from the local registrar or county recorder in the county of birth.
- Having someone who is not on the form's list of homeless services providers complete Section II.
- Leaving the Section I box unchecked, so it is unclear whether the requestor is homeless or acting for a homeless child or youth.
- Omitting the printed name of the homeless child or youth in Section I when requesting on that child's behalf.
- Leaving out the printed name of the homeless person in Section II, where the provider verifies who is homeless.
- Expecting more than one fee exempt birth record per eligible person on a single application.
- Treating the affidavit as the whole request; the other requirements of the birth record application still apply.
Frequently asked questions
What is the Affidavit of Homeless Status for a fee exempt birth certificate?
It is a California Department of Public Health form that verifies a person's homeless status. With it, a local registrar or county recorder issues a certified copy of a birth record without a fee, as Health and Safety Code Section 103577 provides.
Who can request a fee exempt birth certificate with this affidavit?
A homeless person, child or youth who can verify that status, on their own behalf. Any person lawfully entitled to request a certified birth record may also request it for a homeless child or youth. Homeless status is defined in 42 U.S.C. Section 11301 et seq.
Who has to sign the affidavit?
Two people sign: the requestor in Section I and an agent of a homeless services provider in Section II. The form says the affidavit is not considered complete unless both have signed.
Who counts as a homeless services provider?
The form lists funded or sanctioned governmental or nonprofit agencies, California-licensed attorneys, local educational agency liaisons or school social workers, state-funded human or public social services providers, and law enforcement liaisons to the homeless population designated by a local police or sheriff's department.
Where do I get a fee exempt copy of a birth certificate?
From the local registrar or county recorder office in the county where the person was born. The form says a fee exempt copy cannot be obtained from the State Registrar, and that the birth record application comes from that county's vital records office.
Can I get more than one free birth certificate?
Each eligible person may receive only one fee exempt birth record per application. Fee exempt requests are still subject to the other requirements of the application for obtaining copies of birth records.
Is this a Ventura County property tax form?
No. Although the Ventura County Clerk-Recorder hosts it among its County Recorder forms, this affidavit is used only to request a fee exempt certified copy of a birth certificate. It has no connection to property taxes.
Can I fill out this affidavit online on FillingPDF?
Yes. You can fill out the PDF online on FillingPDF and download or print it. FillingPDF is an independent service and does not submit the affidavit; you deliver it to the county office yourself, and both required signatures are still needed.
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