Form Dh-429 - Application For Amendment To Florida Birth Record

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State of Florida

Department of Health – Office of Vital Statistics

APPLICATION FOR AMENDMENT TO FLORIDA BIRTH RECORD

. TYPE OR PRINT

IMPORTANT: Read the entire application form before completing

Requirement for ordering: If you are an eligible applicant, complete and sign this application, state your relationship to registrant and provide a copy of valid photo identification. If you are an attorney

representing an eligible person, you need only sign, provide professional license or bar number, indicate name of person whom you represent and their relationship to the registrant in the appropriate spaces

below. If applicant is not an eligible person, an Affidavit to Release a Birth Certificate, DH Form 1958, must be completed and signed by an eligible person before a notarizing official and submitted in

addition to this application form. Acceptable forms of photo identification are: Driver’s License, State Identification Card, Passport, and/or Military Identification Card.

NAME ON OR FOR

FIRST

MIDDLE

LAST

SUFFIX

NEW BIRTH RECORD

OF REGISTRANT

FIRST

MIDDLE

LAST

SUFFIX

NAME AS RECORDED

ON CURRENT BIRTH

RECORD

MONTH

DAY

YEAR (4-DIGIT)

AGE

STATE FILE NUMBER (IF KNOWN)

SEX

DATE OF BIRTH

HOSPITAL

CITY OR TOWN

COUNTY

PLACE OF BIRTH

FLORIDA

LAST NAME PRIOR TO FIRST MARRIAGE (if applicable)

FIRST

MIDDLE

SUFFIX

MOTHER’S / PARENT’S

NAME

LAST NAME PRIOR TO FIRST MARRIAGE (if applicable)

FIRST

MIDDLE

SUFFIX

FATHER’S / PARENT’S

NAME

CHECK TYPE OF AMENDMENT::

Adoption

Correction

Legal Name Change

Paternity Establishment

$20.00 AMENDMENT PROCESSING FEE includes the issuance of ONE certification

Quantity

Amount

= 1

$20.00

FEES ARE NONREFUNDABLE: See information entitled “Fees” on page 2.

additional certification: $9.00

= $9.00

$9.00

Other additional certifications (after the 1

additional certification) are $4.00 each.

$4.00

RUSH ORDERS (Optional): $10.00 per order. Envelope must be marked “RUSH”.

Yes

(Refer to information entitled Response Time)

TOTAL AMOUNT ENCLOSED: Check or money order payable to Vital Statistics in U.S. Dollars (DO NOT SEND CASH)

Florida Law imposes an additional service charge of $15 for dishonored checks.

APPLICANT/MAILING INFORMATION

Any person who willfully and knowingly provides any false information on a certificate, record or report required by Chapter 382, Florida Statutes, or on any application or

affidavit, or who obtains confidential information from any Vital Record under false or fraudulent purposes, commits a felony of the third degree, punishable as provided in Chapter

775, Florida Statutes.

Applicant’s Name

FIRST

MIDDLE

LAST (INCLUDING ANY SUFFIX)

RELATIONSHIP TO

REGISTRANT

TYPE OR PRINT

DELIVERY ADDRESS (INCLUDE APT. NUMBER, IF APPLICABLE)

CITY

STATE

ZIP CODE