Fillable Printable Affidavit for Correction English Web
Fillable Printable Affidavit for Correction English Web
Affidavit for Correction English Web
Mail to: Center for Health Statistics
P.O. Box 47814
Olympia, WA 98504-7814
360-236-4300
Affidavit for Correction
This is a legal document. Complete in ink and do not alter.
STATE OFFICE USE ONLY
State File Number
Fee Number Initials Date Affidavit Number
R
e
q
u
i
r
e
d
Required information must match current information on record
Record Type:
Birth
Death
Marriage
Dissolution (Divorce)
1. Name on Record:
First Middle Last
2. Date of Event: 3. Place of Event:
(City or County)
4. Father/Parent Full Birth Name (Spouse A for Marriage or Dissolution)
First Middle Last/Maiden
5. Mother/Parent Full Birth Name (Spouse B for Marriage or Dissolution)
First Middle Last/Maiden
6. Name of Person Requesting Correction: Relationship to
Person on Record:
Self
Parent(s)
Guardian
Funeral Director
Informant
Other
(specify)
7. Return Mailing Address:
Post Office Box or Street AddressCity State Zip
Telephone Number:
( )
Email Address:
Use the section below for requesting any changes on the record.
The record is incorrect or incomplete as follows:
The record now shows:The true fact is:
8. 9.
10. 11.
12. 13.
14. 15.
I declare under penalty of perjury under the laws of the State of Washington that the forgoing is true and correct
16a. Signature: 16b. Signature of 2
nd
parent (if required):
Printed name: Date: Printed name: Date:
INSTRUCTIONS – go to www.doh.wa.gov for more information
Required documentary proof must be submitted with the affidavitand must include full name and birth date.Examples of proof include:
Birth/Marriage/Divorce record
Certificate of Naturalization
Military record (DD-214)
Social Security Numident Report
School transcripts
Passport
Hospital/medical record
Green/Permanent Resident card (I-551)
Driver’s license, Social Security card or hospital decorative birth certificate cannot be used as proof
Birth Certificates
1. Only a parent(s), legal guardian (if the child is under 18), or the named individual (if 18 or older) may change the birth certificate
2.
The proof(s) must match the asserted fact(s). For example, if the affidavit says the name should be Mary Ann Doe, the proof must show the name to be
Mary Ann Doe
3. Documentary proof must be five or more years old or established within five years of birth
Child under 18
If legal guardian(s), include certified court order proving guardianship
Up to age one, last name can be changed once to either parents’ name
on certificate (can be any combination of the first, middle or last names)*
After age one, a court order is required to change the last name
No proof is required to change the first or middle name*
To correct parent’s information, one documentary proof is required.
To correct the sex of the child, one documentary proof from a medical
provider is required
Adult (18 years or older)
Only the adult can change his or her birth certificate.
If the first or middle name is missing, three pieces of documentary proof are
required
If the first, middle and/or last name is misspelled, or date of birth is incorrect, two
pieces of documentary proof are required
To correct parent’s birth date, place of birth, or name, one documentary proof is
required
*To change any part of the name of a child using this form,signatures from both parents listed on the certificate are required. If one parent is deceased,
submit a death certificate with request.
This affidavit cannot be used to add a father to a birth certificate (use paternity acknowledgment form DOH 422-032)
Death Certificates
1. Only the informant, the funeral director, or executors/administrators (if evidence confirming such position is presented) may change the non-medical
information. Proof is required to make changes if requested by a family member not listed as the informant on the certificate (family members are spouse or
registered domestic partner, parent, sibling or adult child or stepchild). Marital status requires a certified copy of a court order if someone other than the
informant is requesting the change.
2. The medical information (cause of death) may be changed only by the certifying physician or the coroner/medical examiner.
Marriage/Dissolution (Divorce) Certificates
1. Personal facts (minor spelling changes in name, date or place of birth or residence) may be changed by the person with one piece of documentary proof
2. To change the date or place of marriage or dissolution, the officiant (marriage) or clerk of court (dissolution) must complete and submit the affidavit
DOH 422-034 January 2015
