Fillable Printable California Affidavit to Amend A Birth Record
Fillable Printable California Affidavit to Amend A Birth Record
California Affidavit to Amend A Birth Record
January 2014
Affidavit To
Amend A
Birth Record
Upon request, this document will be made available in
Braille, large print, audiocassette, or computer disk.
To obtain a copy in one of these alternate formats, please
call or write:
California Department of Public Health
Vital Records - M.S. 5103
P.O. Box 997410
Sacramento, CA 95899-7410
Telephone: (916) 445-2684
California Relay: 711/1-800-735-2929
http://www.cdph.ca.gov/certlic/birthdeathmar/Pages/default.aspx
Affidavit to Amend a Birth Record
January 2014
1
Amending a Birth Certificate
What information
can be changed with
an amendment?
Amendments are used to correct errors on the birth certificate.
Amendments may not be used to change information on the certificate
that requires a court order.
Amendments can be used to:
Correct spelling errors.
Add information to blank items.
Correct the spelling of the parents’ names or their statistical
information – please provide a copy of their birth certificate
(or other supporting documentation, such as passport or
driver’s license) to support the change.
Amendments cannot be used to:
Completely change first, middle, or last name of registrant
(person listed on the certificate).
Transpose first and middle name of registrant.
Add to or delete first, middle, or last name of registrant.
Translate registrant’s name into another language (e.g., Juan
to John).
These items can only be changed through a court order. For more
information on this process, you can print our informational pamphlet
(Court Order Name Change) from our website (address on front
page of this pamphlet), or you can call our Customer Service Unit at
(916) 445-2684 and they will mail you a copy.
To change the parents’ names on the child’s birth certificate, you must
go to court for an adjudication (decision). For more information on
this process, you can print our informational pamphlet (Adjudication
of Facts of Parentage) from our website (address on front page of
this pamphlet), or you can call our Customer Service Unit at
(916) 445-2684 and they will mail you a copy.
The following items cannot be changed or removed on registered
certificates:
Signatures.
Informant or certifiers.
Affidavit to Amend a Birth Record
January 2014
2
I want to change
or add the
father/parent
on my child’s birth
certificate.
Can I do this with
an amendment?
No. To change or add the father/parent to your child’s birth certificate,
you will have to complete one of the following forms:
Acknowledgement of Paternity/Parentage: To add the
father/parent if he was not identified on the child’s original birth
certificate. This form must be signed by both parents (if either
parent refuses to sign the Acknowledgement form, you will need
to go to court using the adjudication process).
Adjudication of Facts of Parentage (This will require you to
petition the Superior Court to make the change):
1.
To change the father/parent identified on the child’s original birth
certificate.
2.
To add the father/parent by court order if either parent refuses to
sign the Acknowledgement of Paternity form.
For more information on these processes, you can print those
informational pamphlets from our website (address on front page of this
pamphlet) or call our Customer Service Unit at (916) 445-2684 and they
will mail you a copy.
What is the fee to
amend a birth
certificate?
Within One Year of the Birth:
There is no fee to amend a record within one year of the date
of the birth (but you do not get a copy of the amended
record).
Exception: Amendments to correct gender errors
always require a $23 fee.
If you want a Certified Copy of the amended record, there is a
$25 fee for each copy.
If the Birth Occurred More Than One Year Ago:
There is a $23 fee, which includes one Certified Copy of the
amended record.
Additional copies are $25.
(Continued)
Affidavit to Amend a Birth Record
January 2014
3
What is the fee to
amend a birth
certificate?
(Continued)
Please Note
Fees should be paid by check or money order payable to CDPH Vital
Records. International money orders for out-of-country requests should
be payable in U.S. dollars.
If you are not paying a fee to process the amendment (it is within
the first year and you are not paying to get a Certified Copy of the
amended record), you will not receive any contact from our office –
we will just amend the record and close the file.
Once we complete the amendment, we will send a copy of the amended
record to the local county recorder so they can update their records.
What do I submit
to amend a birth
certificate?
You will need to complete an Affidavit to Amend a Record, VS 24
form.
Although this item is not required, it would help our staff if you
could include a photocopy of the current birth certificate if you
have it (this helps us identify the exact record to be amended).
To correct names listed on the birth certificate that are the result
of a hospital error, you must provide documentation from the
hospital to support the correction.
If parents are changing their information on their child’s birth
certificate, include a copy of their birth certificates (or other
supporting documentation, such as passport or driver’s license)
to support the change.
If you are requesting a Certified Copy of the amended record, you
must include a notarized Sworn Statement (see next section for
more information).
Mail the following items to our office using the address on the
front of this pamphlet:
Completed VS 24 form.
Appropriate fee.
Notarized Sworn Statement (if copy of amended record is
being issued).
Hospital documentation (if due to hospital error).
Photocopy of parent’s birth certificate (if appropriate).
Photocopy of current birth certificate (if you have it).
If any of the required items are not included, your request will be
returned to you for correction.
Affidavit to Amend a Birth Record
January 2014
4
Why do I need a
Sworn Statement?
Effective July 1, 2003, a new law changed the way we issue birth and
death certificates. To help protect against identity theft, the law requires
that only an authorized person (as defined by law) may receive a Certified
Copy of a birth or death record. In order to receive the Certified Copy, you
must sign (and notarize) the Sworn Statement declaring under penalty of
perjury that you are authorized by law to receive the Certified Copy.
Only one notarized Sworn Statement is required for multiple amendments
submitted at the same time. But the Sworn Statement must include the
name of each person whose record is being amended, and your
relationship to that person.
You do not have to complete the attached Application for Certified Copy
of Birth Record, but please read the first page for the definition of an
“authorized” person before completing the Sworn Statement.
Where can
I get the
VS 24 form?
Because the amendment document becomes part of the official record, it
must be an original form (our office uses a special bond paper).
Photocopies are not acceptable. One application form is included if you
receive this pamphlet by mail. If you need additional copies of the VS 24
form, or are accessing this pamphlet on our website:
Order forms electronically at:
https://apps.cdph.ca.gov/AutoForm2/default.aspx?af=1184
.
Because of the volume of phone calls we receive, the Internet is
usually a faster process for our customers than calling our
Customer Service Unit.
Call our Customer Service Unit at (916) 445-2684.
You can also get the form from the County Recorder or County
Health Department in any California county.
How do I
complete the
VS 24 form?
A sample of what a completed form should look like is attached.
PART I:
Complete the information exactly as it appears on the current
birth certificate.
Note: If you need a copy of your child’s current birth certificate to
complete this section, you can get a copy by completing the
Application for Certified Copy of Birth Certificate (attached) and
submitting the application, notarized Sworn Statement, and $25 fee
to our office.
(Continued)
Affidavit to Amend a Birth Record
January 2014
5
How do I
complete the
VS 24 form?
(Continued)
PART II:
Item 8: Enter the item number from the current birth certificate that
needs to be corrected. List only one item per line.
Item 9: Enter the incorrect information as it appears on the current
birth certificate.
Item 10: Enter the correct information as it should appear on the birth
certificate.
Item 11: Briefly state the reason for the correction.
Who may sign
supporting
affidavits?
Items 12A and 13A on the VS 24 form:
Two persons having knowledge of the facts must complete the
supporting affidavits. See next section for additional information.
The signed affidavits must be included on the bottom of the VS 24
form – and not as a separate document.
Two signatures are required.
Are there situations
where specific
persons must sign
the affidavits?
Yes.
When correcting information that was the result of hospital
error: A member of the medical records staff must sign one of the
affidavits.
When correcting the date, time, or place of birth, or when
correcting medical and health information: The certifying
physician, certified nurse midwife, physician’s assistant, or certified
nurse who attended the birth must sign one of the affidavits. (If the
physician is not available, the affidavit may be signed by the
hospital administrator or the administrator’s designated
representative of the hospital where the birth occurred.)
What makes a
VS 24 form
“acceptable?”
Important Information
Birth certificates are legal documents that must hold up in any court,
unchallenged as to their accuracy and reliability.
Because the amendment you submit becomes an actual part of this legal
document, it must adhere to strict guidelines:
Every item on the amendment must be completed.
The amendment form must be an original, not a photocopy.
(Continued)
Affidavit to Amend a Birth Record
January 2014
6
What makes a
VS 24 form
“acceptable?”
(Continued)
Because the amendment form becomes part of the official record,
every word and letter must be extremely clear and legible. Using a
typewriter to complete the form ensures that the information is
interpreted clearly.
If you are not able to type the amendment, it is extremely important
that you take the extra time to print very clearly and legibly.
Documents that are not legible will be returned to you to complete
again.
Only black ink is acceptable.
There cannot be any erasures, whiteout, or alterations.
How long will it
take to process
the amendment?
The processing time for birth amendments can be located on our website at:
http://www.cdph.ca.gov/certlic/birthdeathmar/Pages/ProcessingTimes.aspx
Once I file the
amendment, what
happens to the
original record?
The original record remains unchanged, and the amendment
becomes page 2 of the birth certificate – making it a two-page
document (per Health and Safety Code Sections 102140 and
103255).
Anyone receiving a copy after the amendment is applied will receive
a copy of both documents.
What if I still
have questions?
If you have read this pamphlet thoroughly and still have questions that
were not answered, please call our Customer Service Unit at
(916) 445-2684. If you are checking the status of your request, please
wait until after the processing time has passed before contacting us.
Note to Customer:
We cannot process your request
unless you complete both sides of
the enclosed amendment form.
The information on both sides is
important information for our
records, and both sides must be
completed in order to process
your request. Thank you.
* * *
June 2010
AFFIDAVIT TO AMEND A RECORD
_______________________________ NO ERASURES, WHITEOUTS, PHOTOCOPIES, ______________________________
STATE FILE NUMBER
OR ALTERATIONS
LOCAL REGISTRATION NUMBER
□
BIRTH
□
DEATH
□
FETAL DEATH
TYPE OR PRINT CLEARLY IN BLACK INK ONLY – THIS AMENDMENT BECOMES AN ACTUAL PART OF THE OFFICIAL RECORD
PART I INFORMATION TO LOCATE RECORD
1A. NAME—FIRST 1B. MIDDLE 1C. LAST
2. SEX
3. DATE OF EVENT—MM/DD/CCYY 4. CITY OF EVENT 5. COUNTY OF EVENT
INFORMATION
AS IT APPEARS
ON ORIGINAL
RECORD
6. FULL NAME OF FATHER/PARENT AS STATED ON ORIGINAL RECORD
7. FULL NAME OF MOTHER/PARENT AS STATED ON ORIGINAL RECORD
PART II STATEMENT OF CORRECTIONS TO BIRTH, DEATH, OR FETAL DEATH RECORD
8. ITEM
NUMBER TO BE
CORRECTED
9. INCORRECT INFORMATION THAT APPEARS ON ORIGINAL RECORD
10. CORRECTED INFORMATION AS IT SHOULD APPEAR
LIST ONE
ITEM PER
LINE
11.
REASON FOR
CORRECTION
We, the undersigned, hereby certify under penalty of perjury that we have personal knowledge of the above facts and
that the information given above is true and correct.
12A. SIGNATURE OF FIRST PERSON
►
12B. PRINTED NAME 12C. TITLE/RELATIONSHIP TO PERSON IN PART I
12D. ADDRESS (STREET and NUMBER, CITY, STATE, ZIP) 12E. DATE SIGNED—MM/DD/CCYY
13A. SIGNATURE OF SECOND PERSON
►
13B. PRINTED NAME 13C. TITLE/RELATIONSHIP TO PERSON IN PART I
AFFIDAVITS
AND
SIGNATURES
TWO
PERSONS
MUST SIGN
THIS FORM TO
CORRECT A
BIRTH, DEATH,
OR FETAL
DEATH
RECORD
13D. ADDRESS (STREET and NUMBER, CITY, STATE, ZIP) 13E. DATE SIGNED—MM/DD/CCYY
STATE/LOCAL
REGISTRAR
USE ONLY
14. OFFICE OF VITAL RECORDS OR LOCAL REGISTRAR
►
15. DATE ACCEPTED FOR REGISTRATION
STATE OF CALIFORNIA, DEPARTMENT OF PUBLIC HEALTH, OFFICE OF VITAL RECORDS FORM VS 24 (REV. 1/08)
LEAVE BLANK LEAVE BLANK
-- -- Doe
Male 05/12/2005 Sacramento Sacramento
John -- Doe Mary Jane Smith
1A -- John
1B -- Michael
10 LA CA
To add child's first and middle names and correct mother's state of birth to California
John Doe Father
1234 Main Street, Sacramento, CA 95817 01/05/2007
Mary Jane Smith-Doe Mother
1234 Main Street, Sacramento, CA 95817 01/05/2007
John Doe
Mary Jane Smith-Doe
APPLICATION TO AMEND A RECORD
TYPE OR PRINT CLEARLY IN BLACK INK ONLY
NO ERASURES, WHITEOUTS, PHOTOCOPIES, OR ALTERATIONS
If an acceptable application to amend the record is registered w
ithin one year of the date of the event, there is no processing fee; however, there is
a fee required for a certified copy.
Enclosed is the fee of $___________________________ for a certified copy of the newly amended record.
If an acceptable application to amend the reco
rd is registered one year or more after the date of the event, there is a fee for filing the affidavit,
which includes one certified copy. There is a fee for each additional certified copy. Please contact your Local Registrar, County Recorder, or the
State Registrar for the current fees, or visit our website at www.cdph.ca.gov.
Enclosed is the fee of $___________________________ for filing the affidavit and one certified copy of the newly amended record.
Enclosed is the fee of $___________________________ for an additional certified copy(ies) of the newly amended record.
______________________________________________ ______________________________________________________________________
Printed Name of Applicant Mailing Address of Applicant
Telephone Number ( ) ________________________ ______________________________________________________________________
City, State, ZIP Code
GENERAL INFORMATION
1. The original certificate cannot be altered.
2.
This amendment becomes a part of the original record, so please type or print clearly in black ink only.
3. Please submit original amendment form only. Photocopies of the amendment form will be rejected.
4. Your certified copy will include a copy of the original certificate with a copy of the amendment.
5.
The certified copy of the certificate and the attached amendment must remain together for the certified copy to be
valid.
READ INSTRUCTIONS CAREFULLY BEFORE COMPLETING THE FORM
1.
This form becomes a part of the original record – type or print clearly in black ink only.
2. No erasures, whiteouts, photocopies, or alterations allowed.
3. Complete Part I, Items 1 – 7, with the information as it appears on the original certificate.
4. Enter the certificate item number(s) to be corrected, either from the original or subsequent amendment, in Part II—Item 8.
List one item per line.
5. Enter the incorrect information that appears on the original certificate in the line(s) provided below Item 9.
6. In Item 10, enter the correct information as it should appear for each item listed in Item 9.
7. Enter the reason for the correction in Item 11.
8. Read the affidavit statement. Two persons who are certifying to the statement of corrections must sign the form.
9. Do not write in Items 14 or 15. This space is reserved for State or Local Registrar use only.
10. Make check or money order payable to the Office of Vital Records. When the paperwork is properly completed and signed
by two parties, return this form, together with the required fee(s), to:
California Department of Public Health
Office of Vital Records
MS 5103
P.O. Box 997410
Sacramento, CA 95899-7410
23.00
John Doe 1234 Main Street
916 555-5555 Sacramento, CA 95817
State of California – Health and Human Services Agency California Department of Public Health
APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD
PLEASE READ THE INSTRUCTIONS ON PAGE 2 BEFORE COMPLETING THIS APPLICATION
As part of statewide efforts to prevent identity theft, California law (Health and Safety Code Section 103526) permits only authorized individuals as listed on the
application to receive certified copies of birth records. All others will be issued Certified Informational Copies marked with the legend, “Informational, Not A
Valid Document to Establish Identity.”
Please indicate the type of certified copy you are requesting:
I would like a Certified Copy. This copy will establish the identity of
the registrant. (To receive a Certified Copy you MUST INDICATE
YOUR RELATIONSHIP TO THE REGISTRANT by selecting from the list
below AND COMPLETE THE ATTACHED SWORN STATEMENT
declaring that you are eligible to receive the Certified Copy. The
Sworn Statement MUST BE NOTARIZED if the application is
submitted by mail unless you are a law enforcement or local or
state governmental agency.)
I would like a Certified Informational Copy. This document will be
printed with a legend on the face of the document that states,
“INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY.”
(A Sworn Statement does not need to be provided.)
NOTE: Both documents are certified copies of the original document on file with our office. With the exception of the legend and redaction of
signatures and Social Security Number, the documents contain the same information.
Fee:
$25 per copy
(payable to CDPH Vital Records). PLEASE SUBMIT CHECK OR MONEY ORDER – DO NOT SEND CASH
(CDPH cannot be held responsible for fees paid in cash that are lost, misdirected, or undelivered).
To receive a Certified Copy I am
:
The registrant (person listed on the certificate) or a parent or legal guardian of the registrant. (Legal guardian must provide documentation.)
A party entitled to receive the record as a result of a court order or an attorney or a licensed adoption agency seeking the birth
record in order to comply with the requirements of Section 3140 or 7603 of the Family Code. (Please include a copy of the court order.)
A member of a law enforcement agency or a representative of another governmental agency, as provided by law, who is conducting official
business. (Companies representing a government agency must provide authorization from the government agency.)
A child, grandparent, grandchild, brother or sister, spouse, or domestic partner of the registrant.
An attorney representing the registrant or the registrant’s estate, or any person or agency empowered by statute or appointed by a court
to act on behalf of the registrant or the registrant’s estate.
Appointed rights in a power of attorney, or an executor of the registrant’s estate. (Please include a copy of the power of attorney, or
supporting documentation identifying you as executor.)
APPLICANT INFORMATION (PLEASE PRINT OR TYPE)
Today’s Date:
Agency Name (If Applicable) Agency Case Number Inmate ID Number
Print Name of Applicant Signature of Applicant Purpose of Request
Mailing Address – Number, Street Amount Enclosed – DO NOT SEND CASH
$ _______ Check $ ______ Money Order
Number of Copies
City
Name of Person Receiving Copies, if Different from Applicant
State/Province
ZIP Code Mailing Address for Copies, if Different from Applicant
Daytime Telephone (include area code)
( )
Country City State ZIP Code
BIRTH RECORD INFORMATION (PLEASE PRINT OR TYPE) Adopted:
No
Yes
(If Yes, see #4 on Page 2)
Complete the information below as shown on the birth record, to the best of your knowledge.
FIRST Name MIDDLE Name LAST Name
City of Birth (must be in California)
County of Birth
Date of Birth – MM/DD/CCYY (If unknown, enter approximate date of birth)
Sex
___Female ___Male
Father/Parent FIRST Name
MIDDLE Name LAST Name (Before Marriage/Domestic Partnership)
Mother/Parent FIRST Name
MIDDLE Name LAST Name (Before Marriage/Domestic Partnership)
BIRTH
VS 111 (01/14) Page 1 of 3
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