Application For Amended Birth Certificate Based On A Court Ordered Name Change Form
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1APPLICATION FOR AMENDED BIRTH CERTIFICATE BASED ON A
COURT ORDERED NAME CHANGE
This form may be used to file a legal name change amendment if submitted with a certified copy of a court ordered name
change or with court information contained in the Court of Continuing Jurisdiction database.
This form may NOT be used to ADD the father’s information if the father’s information has been left blank on the
original birth certificate.
This form may NOT be used to REMOVE the father’s information contained on the original birth certificate.
•
The fee to file a legal name change amendment is $15.00.
•
The additional fee of $22.00 is needed to issue one certified copy of the amended birth certificate.
•
The total fee of $37.00 is needed if one copy of the birth certificate is requested after the change is completed.
Mail fee and documents to: Vital Statistics Unit
P.O. Box 12040
Austin, Texas 78711-2040
Toll free telephone number: (888) 963-7111
REQUIRED INFORMATION
1.
Applicant’s Name: __________________________________________________________________________
2.
Mailing Address: ___________________________________________________________________________
3.
City: ________________________________ State: _______________________ Zip Code: _______________
4.
Telephone Number: _________________________________________________________________________
(8:00 am through 5:00 pm)
New Name of Registrant: ____________________________________________________________________
5.
Name of Registrant Before Change: ___________________________________________________________
6.
7.
Date of Birth: ___________________ Place of Birth: ______________________________________________
(City)
(County)
8.
Full Name of Father: ________________________________________________________________________
9.
Full Maiden Name of Mother: _________________________________________________________________
WARNING:
THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT CAN BE 2-10 YEARS IN PRISON AND A FINE OF UP
.
TO $10,000
(HEALTH AND SAFETY CODE, CHAPTER 678, SEC 195.003)
INFORMATION IN CCJ DATABASE
(COURT INFORMATION)
CAUSE NUMBER: _____________________________________ COURT: ______________________________
DATE GRANTED: ___________________ COUNTY: _____________________________ STATE:__________
□
□
INFORMATION MATCH FOUND:
YES
NO
VS 2318.1a Revised 12/2005
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