Certificate of Origin

for Your State

This Certificate of Origin is for use in certifying a motion pictures origin. This Certificate contains the title of the picture, the production company, country of origin and years of production and release. This form is available for immediate download.

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This Certificate of Origin is for use in certifying a motion picture’s origin. This Certificate contains the title of the picture, the production company, the director and cast members, the country of origin and years of production and release. This Certificate of Origin must be signed by the Licensor in the presence of a notary public.


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This attorney-prepared packet includes:
  1. General Information
  2. Certificate of Origin
State Law Compliance: This form complies with the laws of all states
This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.
 
Certificate of Origin
 
 
“_________________” (the “Picture”)
 
Production Company:      _________________
Selling Company:      _________________
Director:         _________________
Cast:            _________________
Year of Production:      _________________
Year of Release:      _________________
Running Time:      _________________ minutes
Theatrical Film Length:   _________________ feet
Color:            _________________
Format:         _________________
Sound Format:         _________________
Country of Origin:      _________________
 
 
LICENSOR: _________________
 
 
BY:_____________________________
      _____________________________
 
 
ACKNOWLEDGEMENT
 
 
State of       )
   )  ss.
County of       )
 
 
 
On the _____ day of ____________, 200__ before me, _______________________________________, personally appeared _________________________ personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
 
WITNESS my hand and official seal.
 
   
 
   
NOTARY SIGNATURE
Number of Pages2
DimensionsDesigned for Letter Size (8.5" x 11")
EditableYes (.doc, .wpd and .rtf)
UsageUnlimited number of prints
Product number#27995
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