Form Hhs-81 - Application For Amendment
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1
2APPLICATION FOR AMENDMENT
Complete and return this form with the documentary evidence required if you wish to amend the original birth certificate. SEE
INSTRUCTIONS AND LIST OF SUGGESTED EVIDENCE ON REVERSE SIDE. (NOTE: If this record is to be used for Social Security or
Passport purposes, check with that office before amending this record.)
[PLEASE ENCLOSE A PHOTOCOPY OF APPLICANT’S CURRENT
PHOTO IDENTIFICATION WHEN SUBMITTING THIS FORM.]
State of_________________________________)
County of________________________________________)
1.
Please list information as it currently appears on the birth certificate you want to amend:
Name at birth ____________________________________________________________________________________
County of birth ______________________________ Date of birth __________________________________________
Father/Parent Name at Birth _________________________________________________________________________
Father/Parent Current Legal Name ____________________________________________________________________
Mother/Parent Name at Birth ________________________________________________________________________
Mother/Parent Current Legal Name ___________________________________________________________________
2.
List items to be corrected:
As Now Listed on Record
Correct Information
_________________________________
___________________________________________________
_________________________________
___________________________________________________
_________________________________
___________________________________________________
_________________________________
___________________________________________________
_________________________________
___________________________________________________
3.
If adding father’s name to record, please complete the following:
Father/Parent Social Security Number _____________
Mother/Parent Social Security Number _________________
4.
I hereby swear that the information listed above is true and correct to the best of my knowledge:
Signature _______________________________________________________________________________________
(Must be signed by one of the parents, the registrant if legal age, or the individual responsible for filing this certificate).
Relationship __________________________________
Phone Number ___________________________________
Address ________________________________________________________________________________________
City _________________________________________
State ____________________________ Zip____________
State of_________________________________)
County of________________________________________)
The foregoing instrument was acknowledged before me this_________Day of___________________, 20___________
By ______________________________________________________________________________________________________________
(Name of person acknowledged)
______________________________________________________________________
Notary Public
5.
Fee Required.
(Please make checks payable to Vital Records)
$16.00 to correct the record.......................................................................................................................
=
$16.00
Number of certified copies of amended record__________ x $17.00 each.............................................
=
TOTAL AMOUNT ENCLOSED...................................................................................................................... =
FOR VITAL RECORDS USE ONLY.
Evidence Accepted:
Code:___________________________________________
1.___________________________________________
2.___________________________________________
3.___________________________________________
4.___________________________________________
Date Amended_____________________________________
5.___________________________________________
By Whom Amended_________________________________
HHS-81 (55081) 4/16
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