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Paternity Consent Form For Birth Registration Form - Kansas Department Of Health And Environment Page 3

Office of Vital Statistics

1000 SW Jackson Street, Suite 120, Topeka, KS 66612-2221

(785) 296-1434

The District Court of __________________________________________________ County, Kansas

In the Matter of the Certificate of Live Birth # ________________________________________ ,

of: ______________________________________________ (name of child as shown on birth certificate)

Order to Prepare New Birth Registration

NOW on this ____________________________________ day of ___________________________________ , ____________, the above

captioned matter is considered.

__________________________________ (mother’s name) and ________________________________________ (father’s name) request

the birth certificate of the child named in the above caption be amended pursuant to KSA 38-1130.

Upon hearing the evidence presented and being fully advised in the premises, the following findings are made:

1. The court has jurisdiction pursuant to KSA 38-1130.

2. The child named in the above caption is a minor.

3. The mother and father, as above named, are the parents of the child and they desire to amend the birth registration of the child.

4. A certified copy of the birth certificate of the child has been exhibited in court.

5. The birth certificate of the child:

Fails to name the (father/mother*) of the child and the (father’s/mother’s*) name should appear thereon as it appears above.

b. Contains an error in the name of the (father / mother / child*). The name on the original birth certificate reads

_______________________________________________________________________________ but should read

____________________________/____________________________/_______________________________.**

First

Middle

Last

Shows the last name of the child as _____________________________________________ and should be changed to that

of the (father/mother*) ____________________________________________ (father’s/mother’s*) last name.

IT IS THEREFORE ORDERED that the State Registrar amend the birth certificate of the child named in the above caption to reflect the

change stated in finding number 5, above.

IT IS FURTHER ORDERED that the State Registrar seal this order, the affidavits accompanying this order, and the original birth

certificate of the child and allow inspection of them only as provided in KSA 38-1128 and amendments thereto.

Affix Court Seal

Certified by:

________________________________

Judge or Authorized Hearing Officer

*Circle the appropriate item in parenthesis.

**This court order is not to be used in lieu of adoption or stepparent adoption procedures.

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Paternity Consent Form For Birth Registration Form - Kansas Department Of Health And Environment Page 3