Birth Correction Statement - Pennsylvania Department Of Health
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1Pennsylvania Department of Health
H105.133 REV. 06/2016
Division of Vital Records
The information appearing on the Certification of Birth is transcribed from the original birth certificate as filed with the Division of
Vital Records. The Division of Vital Records reserves the right to accept or reject any correction.
Instructions to Correct Birth Certificate:
Complete the affidavit form below in the presence of a Notary Public. Upon receipt and review of the documentation and notarized
affidavit, the Division of Vital Records will determine if the correction can be processed.
An original document that supports the correction(s) requested must be submitted, such as marriage record, baptismal record, school
record, military record, etc.
The person(s) requesting the correction must include with the notarized affidavit a completed birth application, the required fee or
Armed Forces information, if applicable, and a clear copy of his/her valid government issued photo ID that verifies his/her name
and current mailing address. Examples of acceptable identification are a state issued driver's license or non-driver photo ID that
verifies the name and current address. If possible, enlarge photo ID on copier by at least 150%. If you do not possess photo ID
that verifies your current mailing address, you may submit two documents that do verify the address such as a lease agreement,
utility bills, pay stub, bank statement, credit card statement, etc.
Mail completed affidavit form, documents, application, fee and ID to:
Division of Vital Records
101 S. Mercer Street
P.O. Box 1528
New Castle, PA 16103
(724) 656-3100
For additional information, visit our website at
DATA
ORIGINAL RECORD NOW READS
CORRECTION(S) DESIRED
(print full names, dates, other)
NAME AT BIRTH
First
Middle
Last
Suffix
DATE OF BIRTH
SEX
FATHER/PARENT
First
Middle
Last
Suffix
MOTHER/PARENT
First
Middle
Last
Suffix
OTHER ERROR
OTHER ERROR
SIGNATURE OF FATHER/PARENT
PRESENT ADDRESS
STREET
SIGNATURE OF MOTHER/PARENT
CITY
STATE
ZIP CODE
SIGNATURE OF PERSON NAMED ON RECORD
PHONE NUMBER (
)
TO BE COMPLETED BY NOTARY PUBLIC ONLY
Notary Instructions:
State of
Use BLUE or BLACK INK for all signatures and/or the
Signed and sworn to before me
this
(Day) of
(Month),
20
notary stamp.
Print name of person(s) appearing before the Notary Public
Do not notarize if there are any alterations, such as: scratch
1.
out, correction fluid, write-over or erasure.
2.
Signature of Notary Public
Do not notarize unless signed by subject (or parent(s) if
under age 18) in the presence of the Notary.
Address of Notary Public
Complete all items in the Notary section and affix your
notary stamp and/or seal.
My commission expires
Notary Stamp and/or Seal
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