Do NOT save this to computer. This for printing and writing to mail in slow mail 5 September 2012 Print this Form | Return to Order Instructions | Repeat Customers: Please check changed address? **_____ changed email address? **______ old address: ____________________________________________ SAMPUBCO - SURROGATE'S RECORDS (scanned) (NO PAPER COPY) Name (PLEASE PRINT):** _____________________________________________________ Email (REQUIRED!):** _______________________________________________________ Street/P.O. Box:** _________________________________________________________ City/State/ZipCode+4:** ____________________________________________________ (out of USA - City, Province, Country, Postal Code) Order (do NOT alter the information as listed onsite in any way): Name of Person: Residence: County of Record: State, County # Vol, Page # Example: DOE, JOHN Anyplace/Year Anycounty XX-50-35-80 1. _________________________________________________________________________ 2. _________________________________________________________________________ 3. _________________________________________________________________________ 4. _________________________________________________________________________ 5. _________________________________________________________________________ 6. _________________________________________________________________________ Cost: Number of records: _______ X USD $12.00 = __________ if by PayPal / Credit Card Number of records: ________X USD $14.00 = ___________if by check MANDATORY INFORMATION TO KNOW: Do NOT staple or tape check to the order. DO NOT COMBINE WITH NATURALIZATIONS OR GUARDIANSHIPS OR WILLS! Mail to: SAMPUBCO P.O. Box 11874 Salt Lake City, UT 84147-0874 STOP! Please check and verify the accuracy of the information. Do NOT forget
to list "County of Record", which is listed at top of the index page the
indexed information is found on.