AFFIDAVIT TO CORRECT OR AMEND A BIRTH CERTIFICATE Instructions
AFFIDAVIT TO CORRECT OR AMEND A BIRTH CERTIFICATE Instructions
1. Please type or print using black or blue ink only and separate the first, middle and last names by using commas.
2. Do not make any alterations after the information has been entered on the affidavit. ALTERATIONS SHALL INVALIDATE THIS AFFIDAVIT and you will be required to complete a new affidavit.
3. The affidavit must be signed in the presence of a notary. If both parents are listed on the birth record and the child's name is being changed, both parents must sign the affidavit.
4. At minimum, the following fields must always be completed on the affidavit: child's name (first, middle and last), mother's name prior to first marriage (first, middle and last), and child's date of birth.
5. A court order submitted with the affidavit must be certified by the court where the order was finalized.
To add a first name, middle name and suffix to a birth record (child not named at birth)
? If the child is 3 months of age or less, the parent or guardian shall submit the following to request the amendment: a completed application, a valid government issued identification or notarized signature on the application, a completed affidavit, and the amendment fee.
? If the child is more than 3 months of age but less than 7 years old, the parent or guardian shall submit the following to request the amendment: a completed application, a valid government issued identification or notarized signature on the application, a completed affidavit, an evidentiary document created within one year after the date of the child's birth that includes the names to be added, and the amendment fee.
? To add the first name, middle name and suffix to a birth record for a child 7 years of age and older, a certified court order that specifies the information to be added or deleted is required. A completed application, a valid government issued identification or notarized signature on the application, a completed affidavit, and the amendment fee must be submitted with the court order.
In addition to the aforementioned requirements, if the request is submitted by a guardian, a certified copy of the court order establishing guardianship is required.
To change a name listed on the birth record (child named at birth)
? If the child is 3 months of age or less, the parent or guardian shall submit the following to request the amendment: a completed application, a valid government issued identification or notarized signature on the application, a completed affidavit, and the amendment fee.
? If your child is over 3 months and less than 1 year of age, the parent or guardian shall submit the following to request the amendment: a completed application, a valid government issued identification or notarized signature on the application, a completed affidavit, an evidentiary document created within one year after the date of the child's birth that includes the name to be added, and the amendment fee.
? To change a name one year or more after birth, the parent or guardian shall submit the following to request the amendment: a certified court order that specifies the information to be added or deleted on the registered birth record. A completed application, a valid government issued identification or notarized signature on the application, a completed affidavit, and the amendment fee must be submitted with the court order.
In addition to the aforementioned requirements, if the request is submitted by a guardian, a certified copy of the court order establishing guardianship is required.
To amend the parent's date of birth, place of birth or mother's name prior to first marriage the parent or guardian shall submit the following to request the amendment: a completed application, a valid government issued identification or notarized signature on the application, a completed affidavit, an evidentiary document (examples: certified copy of the parent's registered birth certificate, passport). Note: If the parent is changing their complete name, then a certified court ordered name change is required. If the mother/father listed an alias name on the registrant's birth record, then a court order listing the alias names and the correct legal name and name prior to first marriage is required to amend the birth record.
To request a correction to a registered birth record
? If the child is 3 months of age or less, the parent, guardian or custodian shall submit the following to request the correction: a completed application, a valid government issued identification or notarized signature on the application, a completed affidavit, if applicable, a certified court order of guardianship or custody, and the correction fee.
? If the child is more than 3 months of age, the parent, guardian or custodian shall submit the following to request the correction: a completed application, a valid government issued identification or notarized signature on the application, a completed affidavit, an evidentiary document that includes the specific information to be corrected, if applicable, a certified court order of guardianship or custody, and the correction fee.
Other Changes Field--this field may be used to specify other requested corrections on the birth record such as mother's date of birth and place of birth, etc. Please specify the field name or number you want to amend in the Data field column on the affidavit.
VS-41 11-16-2016
DECLARACI?N JURADA PARA CORREGIR O ENMENDAR UN CERTIFICADO DE NACIMIENTO Instrucciones
1. Escriba en letra de molde o imprima con tinta negra o azul ?nicamente y separando con comas el primer nombre, el segundo nombre y el apellido.
2. No modifique los datos una vez que la informaci?n haya sido ingresada en la declaraci?n jurada. LAS MODIFICACIONES INVALIDAR?N ESTA DECLARACI?N JURADA y tendr? que completar una nueva declaraci?n jurada.
3. La declaraci?n jurada debe firmarse en presencia de un notario. Si en el certificado de nacimiento figuran ambos padres y se est? cambiando el nombre del ni?o, ambos padres deben firmar la declaraci?n jurada.
4. Como m?nimo, los siguientes campos de la declaraci?n jurada se deben completar siempre: nombre del ni?o (primer nombre, inicial del segundo nombre, apellido), nombre de soltera de la madre (primer nombre, inicial del segundo nombre, apellido) y fecha de nacimiento del ni?o.
5. Una orden judicial enviada con la declaraci?n jurada debe estar certificada por el tribunal donde se finaliz? la orden.
Para agregar un nombre, segundo nombre y sufijo a un certificado de nacimiento (ni?o no nombrado al nacer)
? Si el ni?o tiene 3 meses de edad o menos, los padres o tutores deben presentar lo siguiente para solicitar enmiendas: una solicitud completa, una identificaci?n v?lida emitida por el gobierno o la firma notariada en la solicitud, una declaraci?n jurada completa y la tarifa por enmienda.
? Si el ni?o tiene m?s de 3 meses pero menos de 7 a?os, los padres o los tutores deben presentar lo siguiente para solicitar la enmienda: una solicitud completa, una identificaci?n v?lida emitida por el gobierno o la firma notariada en la solicitud, una declaraci?n jurada completa, un documento probatorio creado dentro del a?o posterior a la fecha de nacimiento del ni?o que incluya los nombres que haya que agregar y la tarifa por enmienda.
? Para agregar el nombre, el segundo nombre y el sufijo a un certificado de nacimiento de un ni?o de 7 a?os o m?s, se requiere una orden de la corte que especifique la informaci?n que es necesario agregar o eliminar. Con la orden de la corte, se debe enviar una solicitud completa, una identificaci?n v?lida emitida por el gobierno o la firma notarizada en la solicitud, una declaraci?n jurada completa y la tarifa de enmienda.
Adem?s de los requisitos antes mencionados, si la solicitud la presenta un tutor, se requiere una copia certificada de la orden judicial que establece la tutela.
Para cambiar un nombre registrado en el certificado de nacimiento (ni?o nombrado al nacer)
? Si el ni?o tiene 3 meses de edad o menos, los padres o tutores deben presentar lo siguiente para solicitar la enmienda: una solicitud completa, una identificaci?n v?lida emitida por el gobierno o la firma notariada en la solicitud, una declaraci?n jurada completa y la tarifa por enmienda.
? Si el ni?o tiene m?s de 3 meses de edad y menos de un a?o, los padres o tutores deben presentar lo siguiente para solicitar la enmienda: una solicitud completa, una identificaci?n v?lida emitida por el gobierno o la firma notariada en la solicitud, una declaraci?n jurada completa, un documento probatorio creado dentro del a?o posterior a la fecha de nacimiento del ni?o que incluya el nombre que haya que agregar y la tarifa por enmienda.
? Para cambiar un nombre un a?o o m?s despu?s del nacimiento, los padres o tutores deben presentar lo siguiente para solicitar la enmienda: una orden de la corte certificada que especifique la informaci?n a agregar o eliminar en el certificado de nacimiento registrado. Con la orden de la corte, se debe enviar una solicitud completa, una identificaci?n emitida por el gobierno v?lida o la firma notarizada en la solicitud, una declaraci?n jurada completa y la tarifa de enmienda.
Adem?s de los requisitos antes mencionados, si la solicitud la presenta un tutor, se requiere una copia certificada de la orden judicial que establece la tutela.
Para enmendar la fecha de nacimiento de los padres, el lugar de nacimiento o el nombre de soltera de la madre, los padres o tutores deben presentar lo siguiente para solicitar la enmienda: una solicitud completa, una identificaci?n v?lida emitida por el gobierno o la firma notariada en la solicitud, una declaraci?n jurada completa, un documento probatorio (por ejemplo: copia certificada del certificado de nacimiento del padre/madre, pasaporte). Nota: Si el padre/madre est? cambiando el nombre completo, entonces se requiere una orden judicial certificada de cambio de nombre. Si el nombre de la madre/el padre indicaba un nombre seud?nimo en el certificado de nacimiento del solicitante, entonces se requiere una orden judicial que indique los nombres seud?nimos y el nombre legal correcto del solicitante y el nombre de soltera de la madre para enmendar el certificado de nacimiento.
Para solicitar una correcci?n a un certificado de nacimiento registrado
? Si el ni?o tiene 3 meses o menos, los padres o tutores deben presentar lo siguiente para solicitar la correcci?n: una solicitud completa, una identificaci?n emitida por el gobierno v?lida o la firma notarizada en la solicitud, una declaraci?n jurada completa, una orden certificada de la corte de la tutela o custodia si corresponde y la tarifa de enmienda.
? Si el ni?o tiene m?s de 3 meses, los padres o tutores deben presentar lo siguiente para solicitar la correcci?n: una solicitud completa, una identificaci?n emitida por el gobierno v?lida o la firma notarizada en la solicitud, una declaraci?n jurada completa, un documento probatorio que incluya la informaci?n espec?fica a corregir, una orden certificada de la corte de la tutela o custodia si corresponde, y la tarifa de enmienda.
Campo Otros cambios--este campo se puede utilizar para especificar otras correcciones solicitadas en el certificado de nacimiento, como por ejemplo la fecha y el lugar de nacimiento de la madre, etc. Especifique el nombre o el n?mero de campo que desea enmendar en la columna Campo de datos en la declaraci?n jurada.
VS-41 11-16-2016
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SAVE AS
AFFIDAVIT TO CORRECT OR AMEND A BIRTH CERTIFICATE
Please use black or blue ink only and separate the first, middle and last names by using commas.
ANY ALTERATIONS SHALL INVALIDATE THIS AFFIDAVIT
DATA
As the Record Reads Now
Correction/Amendment Desired
Child's Name (first, middle, last)
Child's Date of Birth (mm,dd,yyyy)
Father's Name (first, middle, last)
Mother's Name Prior to First Marriage (first, middle, last) Other Changes (list field name or number) Other Changes (list field name or number) Other Changes (list field name or number) Other Changes (list field name or number) Other Changes (list field name or number) Other Changes (list field name or number)
I attest the corrections/amendments requested above are accurate, true and valid to the best of my knowledge .
Notary Public:
Father's Signature State of _____________ County of ______________, ___day of _____________, 20______, before me personally appeared ______________________________(name of signer), whose identity was proven to me on the basis of satisfactory evidence to be the person whose name is subscribed to this document, and who acknowledged that he/she signed the above/attached document.
Notary Stamp/Seal
Notary Signature and Expiration Date of Commission
9 Mother's Signature 9 Custodian or Guardian (check one--the custodian or guardian must present a valid, certified custody or guardianship court order)
State of _____________ County of ______________, ___day of _____________, 20______, before me personally appeared ______________________________(name of signer), whose
Notary Stamp/Seal
identity was proven to me on the basis of satisfactory evidence to be the person whose name is
subscribed to this document, and who acknowledged that he/she signed the above/attached document.
Notary Signature and Expiration Date of Commission
Registrant's Signature
(must be at least 18 years of age or show proof of emancipation with a certified court order or certified Marriage certificate)
State of _____________ County of ______________, ___day of _____________, 20______, before me personally appeared ______________________________(name of signer), whose
Notary Stamp/Seal
identity was proven to me on the basis of satisfactory evidence to be the person whose name is
subscribed to this document, and who acknowledged that he/she signed the above/attached document.
Notary Signature and Expiration Date of Commission
Affidavit Processed By
FOR OFFICE USE ONLY Office Location
VS-41 11-16-2016
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