Minnesota - Sworn Statement

I, __________________________ swear/affirm under penalty of perjury under the laws of the State of Minnesota, that I am an authorized person, as defined in Minnesota Statutes Section 144.277, and am eligible to receive a certified copy of the birth or death record of the following individual(s):

Name of person listed on Certificate                            Relationship to person on Certificate

1)   2)   3)   4)

Sworn this____day of _______, 20___      City:______________________  State____________

Day                 Month           Year

Signature______________________________________________________

Note: When submitting your order, you must have your sworn statement notarized using the Certificate of Acknowledgment below.

Certificate of Acknowledgment

State of __________________)                                                    ) ss County of_________________ )

On ___________,  Before me personally appeared ________________________________,

Personally known to me, or

Proved to me on the basis of satisfactory evidence, to be the person whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her authorized capacity, and that by his/her signature on the instrument the person, or entity upon behalf of which the person acted, executed the instrument.

_______________________________________ Notary Signature

WITNESS my hand and official seal.

(Notary Seal) Seal MUST be visible on a faxed form.