Form Vs-166 - Application For A New Birth Certificate Based On Parentage (Page 2 of 2) in pdf

THIS FORM (with an attached court order or marriage license, or a filed Acknowledgment of Paternity in

the AOP Registry) MAY BE USED TO:

• Add the biological father’s name and information to the birth certificate when the father’s information is

blank on the original birth certificate. Evidence needed: a certified copy of a court order establishing the

paternity of the child, OR a filed Acknowledgment of Paternity in the AOP Registry if the biological parents are

not married to each other, OR the marriage license of the biological parents if they are now married to each other,

• Change the name and information of the father listed on a child’s birth certificate to the biological father’s

name and information. This requires a certified copy of a court order OR an Acknowledgment of Paternity signed

by all three parties (the biological mother, the biological father, and the father presently listed on the birth

certificate) and filed in the Acknowledgment of Paternity Registry.

• Remove the father or mother’s information. This requires a certified copy of a court order. Please Note: A

Termination of Parental Rights will not remove a biological parent’s information from the birth certificate unless

the court order specifically states the biological parent’s name and information are to be removed.

• Substitute the Intended Parents’ names on the birth certificate based on a gestational agreement. This

requires a certified copy of a court order.

SPECIAL INSTRUCTIONS:

♦ If a marriage license or an Acknowledgment of Paternity is being used as evidence, BOTH parents must

sign the application before a notary public.

♦ If a certified copy of a court order is being used as evidence to change the birth certificate, only one parent

is required to sign the application before a notary public.

♦ If you are the father listed and you are having your name removed, a certified copy of a court order is

required to make any change to the child’s name. You are no longer a qualified applicant to receive a copy of the

child’s new birth certificate. Please submit only the $25.00 filing fee. You will receive notification when the

change is made.

♦ A legal guardian or the father listed on the birth certificate may sign the application before a notary public

if a certified copy of a court order establishing or removing paternity is presented as evidence with this

application.

♦ If one or both parents are deceased, a court order is required to file a new birth certificate to add the

biological father’s name and information.

♦ If a birth certificate has previously been changed based on paternity or a court order, a court order is

needed to file a new birth certificate with different information.

NO CHANGES WILL BE MADE TO A BIRTH CERTIFICATE WITHOUT THE

FILING FEE

The fee to file a new birth certificate based on paternity, removal of a father or mother’s information,

or a gestational agreement is $25.00. The additional fee for a certified copy of the new birth record

is $22.00. If you have any questions, please call (888) 963-7111.

VS-166 revised 12/2005

Form Vs-166 - Application For A New Birth Certificate Based On Parentage Page 2