Dh Form 1905 - Certified Statement Of Final Order Of Affirmation Of Parental Status Page 2

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TYPE USING BLACK RIBBON
INSTRUCTIONS
Please type using black ribbon
(Prompt submission of this statement, when properly completed, will ensure the timely filing of a new birth certificate.)
Pursuant to s. 742.16(8), Florida Statutes, within 30 days after entry of the order, the clerk of the court shall prepare a
certified statement of the order for the state registrar of vital statistics. Please mail to Department of Health, Bureau of
Vital Statistics, P.O. Box 210, Jacksonville, FL 32231-0042.
Please provide all information so that the certificate prepared will be complete.
If the fee is accompanying this statement, please DO NOT send cash. Please send a check or money order made payable
to Office of Vital Statistics. DH Form 429, Application for Amendment to Florida Birth Record, should be used when
remitting the fee.
If the fee is not remitted, a new record will be filed and a notice will be sent to the attorney or parents advising of the
filing and of the amendment-processing fee due.
GENERAL INFORMATION
TO OBTAIN A SUPPLY OF THIS FORM:
Write to the Department of Health, Office of Vital Statistics, ATTN:
Administrative Services, P.O. Box 210, Jacksonville, FL 32231-0042. Requests must be made on official letterhead and
must contain a signature of an authorized clerk. This form is printed by the Bureau of Vital Statistics and will be issued in
a quantity of twenty-five (25).
DH Form 1905, 10/2002

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