Affidavit For Correction Of A Vital Record Form
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1Montana Department of Public Health &Human Services
Office of Vital Statistics
(PO Box 4210, Helena, MT 59604)
AFFIDAVIT
For Correction of a Vital Record
I hereby swear that the record of BIRTH/DEATH for__________________________________________
(Circle one)
(Current Name on Record)
who was born/died in the city of _______________________ County of __________________________
(Circle one)
on ________________________________ is incorrect or incomplete as follows:
(Current date on birth/death record)
The record now shows:
The true facts are:
_________________________________________
_______________________________________
_________________________________________
_______________________________________
_________________________________________
_______________________________________
_________________________________________
_______________________________________
_________________________________________
_______________________________________
I have the consent of all parties concerned in stating these true facts. I further declare that if the corrected
certificate is questioned, I will assume the responsibility of furnishing proof of the corrected item to the
questioning agency. It is recommended to retain copies of all supporting documents.
The probative value of an altered certificate of birth is determined by the judicial or administrative body before whom the certificate is offered as
evidence. 50-15-204(5) M.C.A.
I further swear that I represent the child/deceased as: Self
Attorney
Parent
Other
(Check one)
(Specify)
Signed ______________________________________
Address ______________________________________
_______________________________________
Phone number_______________________________________
State of:______________________
County of:____________________
personally appeared before me and whose identity I proved on the basis of
To be completed by Notary Public
satisfactory evidence to be the signer of the above instrument.
Subscribed and sworn to before me this
day of
20____
_____________________________________________
Notary’s Signature
Printed Name:_________________________________
Notary Public in and for the State of ________________
SEAL
Residing at ___________________________________
My commission expires__________________________
V.S.No. 14
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