This is a printable, fill‑in‑the‑blank form that residents of San Juan, Texas use to request an official, state‑certified copy of a birth or death certificate. The form asks for the applicant’s personal details, the person named on the certificate, the relationship to that person, and the reason for the request. It lists the fees for the certificates and optional protective envelopes, a $10 fee for a record search, and warns of a criminal penalty (up to 12 years in prison and a $10,000 fine) for providing false information.
| Birth certificate certified copy fee | $23.00 |
| Death certificate certified copy fee | $21.00 |
| Additional death certificate copy fee | $4.00 each |
| Record search fee | $10.00 |
| Poly envelope (letter size) fee | $4.00 |
| Poly envelope (legal size) fee | $4.00 |
| Vitals records envelope fee | $2.00 |
| Maximum criminal penalty for false statement | Up to 12 years prison and $10,000 fine |