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Blank Texas Vs 142 3 PDF Form

The Texas VS 142 3 form is an official application used to request certified copies of birth or death records in Texas. This form ensures that individuals can obtain vital records necessary for various personal and legal purposes. Completing the form accurately and including a valid photo ID is essential for processing your request efficiently.

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The Texas VS 142 3 form serves as a critical tool for individuals seeking certified copies of birth or death records in the state of Texas. This form is essential for a variety of purposes, including legal identification, genealogical research, and personal record-keeping. When completing the form, applicants must provide specific details such as the full name of the individual on record, their date of birth or death, and the names of their parents. Each request requires a valid photo ID to be submitted alongside the application, ensuring that the identity of the requester is verified. The form also outlines the associated costs for obtaining certified copies, with different fees depending on the type of record requested. For instance, a certified birth certificate costs $22, while additional copies are available for $3 each. Furthermore, applicants can opt for express delivery services at an additional charge. It is important to note that refunds are only available upon written request, and the search fee is non-refundable if the record is not found. The form emphasizes the seriousness of providing accurate information, highlighting that falsifying details can lead to severe penalties. By understanding the requirements and implications of the Texas VS 142 3 form, individuals can navigate the process more effectively, ensuring their requests are processed without unnecessary delays.

Texas Vs 142 3 Preview

VS–142 (1/26)
MAIL APPLICATION FOR DEATH RECORD
PLEASE PRINT CLEARLY.
INCLUDE A COPY OF YOUR (APPLICANT) VALID ID WHEN SENDING IN THE REQUEST. APPLICATION MUST BE ORIGINAL
(INCLUDING SIGNATURE). NO CROSS OUT OR WHITE OUT WILL BE ACCEPTED. SEE INSTRUCTIONS ON BACK.
Step 1: YOUR INFORMATON AND SHIPPING ADDRESS (PLEASE PRINT)
Your Name (First, Middle, Last Name):
Street Address:
City:
State:
Zip Code:
Email Address:
Daytime
Phone Number:
Your relationship to Person named on Certificate (Check One): ☐ Child
☐ Spouse
☐ Parent ☐ Sibling
☐ Grandparent ☐ Funeral Home ☐ Other:_______________________
☐ I authorize mailing to the address below instead of my mailing address listed above.
Name:
Address to Send to if different than noted above:
City:
State:
Zip Code:
Reason for Request:
☐ Records ☐ Estate ☐ Insurance ☐ Other: _______________________________
Step 2: INFORMATION FOR PERSON NAMED ON DEATH RECORD (Must be completed to Identify Record Requested)
FULL NAME
ON RECORD:
Middle Name
Last Name
DATE OF
DEATH:
Month
Day
Year
DATE OF
BIRTH:
Month
Day
Year
SEX:
SOCIAL SECURITY NUMBER:
- -
PLACE OF
DEATH:
County
TEXAS ONLY
FULL NAME OF
PARENT 1:
Middle Name
Maiden Last Name (Before first marriage)
FULL NAME OF
PARENT 2:
Middle Name
Maiden Last Name (Before first marriage)
Step 3: COST & FEES (NOT REFUNDABLE, if Record Not found) | Step 4: AFFIDAVIT (NOTARY SECTION)
ONLY applications for death certificates (NOT death
verifications) submitted by mail need to be notarized
STATE OF _________________________
COUNTY OF________________________
This instrument was acknowledged before me
on________________
(Date)
By________________________________________
(Printed Name of applicant acknowledging)
_______________________________
(Notary Public’s Signature)
(Personalized Seal)
WARNING: IT IS A FELONY TO FALSIFY INFORMATION ON THIS
DOCUMENT. THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT ON THIS FORM OR SIGNING A FORM WHICH CONTAINS A FALSE STATEMENT IS 2
TO 10 YEARS IMPRISONMENT AND A FINE OF UP TO $10.000. (HEALTH AND SAFETY CODE, CHAPTER 195, SEC. 195.003.)
READ & SIGN (Applications without signatures or attached valid ID will NOT be accepted for processing)
Signature of Applicant __________________________ Date Signed (MM/DD/YYYY) _____/_____/_________
OFFICE USE ONLY ☐ CHECK ☐ MONEY ORDER
REMITTANCE NO. ____________ CERT. #_______________________
DATE ______________________ AMOUNT $_____________________
DOCUMENT CONTROL # ______________________________________
__________________________________________________________
Select Record Type:
Qty
Price/each
Total
☐ First Death Certificate
x $20.00
$
☐ Additional Death Certificate(s)
x $3.00
$
☐ Death Verification
(letter, not official certificate)
x $20.00
$
For urgent requests, orders may
be EXPEDITED by sending the order
through an overnight mail service, such as: FEDEX,
LoneStar, or UPS to our
physical address:
DSHS – VSS MC 2096, 1100 W. 49th St., Austin, TX
78756
and paying the below expedited processing fee.
☐
Expedited Processing (estimated 4 weeks)
$25.00
All orders are returned free of charge by USPS regular mail. For
expedited return mail service, select
one
of the overnight return
shipping methods below
.
☐
Overnight Return Mail (for shipping within USA)
$16.00
☐
USPS Express Return Mail (for shipping to PO Box
ONLY)
$22.95
☐ I wish to make a voluntary contribution of $5.00 to
promote healthy early childhood by supporting the Texas
Home Visitation Program administered by the Office of Early
Childhood Coordination of Health and Human Services.
$5.00
Total Due:
$
VS–142 (1/26)
MAIL APPLICATION FOR DEATH RECORD
Processing times are estimates and subject to change with an increased volume of customer applications.
FAILURE TO PROVIDE INFORMATION REQUESTED ON THIS FORM MAY RESULT IN SIGNIFICANT
PROCESSING DELAYS AND/OR DENIAL OF YOUR APPLICATION.
Walk In: Same day service in most cases. Hours are Monday-Friday 8:00 am - 4:00 pm. DSHS - Vital Statistics Section, 1100 W. 49th
St., Austin, TX 78756
Online Orders: Visit www.texas.gov to order online. Online orders are mailed 20-25 business days after receipt of the request.
Mail In Orders: Processed and mailed 6 - 8 weeks after receipt of the request. Mail to: DSHS - VSS, P.O. Box 12040, Austin, TX
78711-2040. For current processing times, please see our website at: https://www.dshs.texas.gov/vital-statistics/processing-times.
Expedited Orders: Processed and mailed 4 weeks after receipt of the request. Must be sent to the Texas Department of State
Health Services - Vital Statistics Section via an OVERNIGHT mail service, such as FedEX, LoneStar, or UPS to: DSHS – VSS MC 2096,
1100 W. 49th St., Austin, TX 78756
Copies of death certificates for deaths that occurred within the past 25 years can be requested only by immediate family members of the
person whose name is on the certificate. See Section 181.1(13) of the Texas Administrative Code for who qualifies as an immediate
family member. An immediate family member is the decedent's child, spouse, parent, sibling, or grandparent.
Applicants who are not immediate family members must provide legal documentation (such as an insurance policy listing the applicant
as the beneficiary) that documents a direct, tangible interest in the death certificate.
The applicant must include a photocopy of his or her valid photo ID issued by a governmental entity. See Section 181.28
of the Texas Administrative Code for a complete list of acceptable forms of identification. You also can see VSS’s
page on acceptable identification in English (https://www.dshs.texas.gov/vital-statistics/acceptable-identification-
id) and Spanish (https://www.dshs.texas.gov/es/vital-statistics/acceptable-identification-id).
Applications for death certificates cannot be processed without a copy of a photo ID or alternate IDs and the
signature of the applicant.
Verification Letter - A verification letter will include the decedent’s name, the date of death, and the county where the death occurred.
Verification letters are available for deaths that have occurred since 1903. Verification letters are not considered legal substitutes for
certified copies of death certificates. The VSS strongly recommends that applicants ensure a verification will satisfy its intended use.
If a record is not on file, our office will issue a “not found” letter.
Customer Checklist
☐ Complete steps 1, 2, and 3 of the application. Please type or print clearly.
☐ Complete step 4 of the application and have it notarized, if requesting a death certificate.
☐ Sign and date the application.
☐ Make sure the application is original and not a photocopy and there are no cross-outs or white-out.
☐ Enclose a copy of a current driver's license, passport or state identification. See complete ID list on our website.
☐ Enclose appropriate fees. Make checks or money orders payable to DSHS - Vital Statistics.
For more information, go to: https://www.dshs.texas.gov/vs/requirements.aspx.
For the status of your request, contact VSS by telephone at 1-888-963-7111 or online at: https://www.dshs.texas.gov/orderstatus/.
⇓ Texas Vs 142 3 PDF

Document Specs

Fact Name Details
Form Purpose The Texas VS-142.3 form is used to request certified copies of birth or death records.
Governing Law This form is governed by the Texas Health and Safety Code, specifically Chapter 195.
Application Requirements Applicants must include a photocopy of a valid photo ID with their request.
Fees for Birth Certificates The cost for a certified birth certificate copy is $22, with additional options for heirloom copies at $60.
Fees for Death Certificates A certified death certificate copy costs $20, and additional copies are available for $3 each.
Refund Policy Refunds are only available upon written request, and search fees are non-refundable if a record is not found.
Mailing Instructions Applications must be mailed to the Texas Vital Records Department at P.O. Box 12040, Austin, TX 78711-2040.
Signature Requirement The applicant must sign the form, confirming the accuracy of the information provided.
Legal Warning Falsifying information on the form is a felony, punishable by 2 to 10 years imprisonment and fines up to $10,000.
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