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: ______/________/20________Notary signature: _____________________________ Date: _____________
My commission expires on: ____/_____/ 20___