Affidavit To Correct Or Amend A Birth Certificate Page 3
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ARIZONA DEPARTMENT OF HEALTH SERVICES
AFFIDAVIT TO CORRECT OR AMEND A BIRTH CERTIFICATE
Please use black or blue ink only and separate the first, middle and last names by using commas.
ANY ALTERATIONS SHALL INVALIDATE THIS AFFIDAVIT
CORRECTION/AMENDMENT
DATA
As THE RECORD READs NOw
DEsIRED
Child’s Name (first, middle, last)
Child’s Date of Birth (mm,dd,yyyy)
Father’s Name (first, middle, last)
Mother’s Maiden Name (first, middle, last)
Other Changes (list field name or number)
Other Changes (list field name or number)
Other Changes (list field name or number)
The undersigned, declare upon oath that to the best of my knowledge and belief such changes and additions as shown on this affidavit are
necessary to make this vital record correct.
Notary Public:
Father’s Signature
State of _____________ County of ______________, ___day of _____________, 20______,
Notary Stamp/Seal
before me personally appeared ______________________________(name of signer), whose
identity was proven to me on the basis of satisfactory evidence to be the person whose name is
subscribed to this document, and who acknowledged that he/she signed the above/attached document.
Notary Signature and Expiration Date of Commission
9 Mother’s Signature 9 Legal Guardian
(check one—the legal guardian must present a valid, certified legal guardianship court order)
State of _____________ County of ______________, ___day of _____________, 20______,
Notary Stamp/Seal
before me personally appeared ______________________________(name of signer), whose
identity was proven to me on the basis of satisfactory evidence to be the person whose name is
subscribed to this document, and who acknowledged that he/she signed the above/attached document.
Notary Signature and Expiration Date of Commission
Registrant’s Signature
(must be at least 18 years of age or show proof of emancipation with a certified court order or certified Marriage certificate)
State of _____________ County of ______________, ___day of _____________, 20______,
Notary Stamp/Seal
before me personally appeared ______________________________(name of signer), whose
identity was proven to me on the basis of satisfactory evidence to be the person whose name is
subscribed to this document, and who acknowledged that he/she signed the above/attached document.
Notary Signature and Expiration Date of Commission
FOR OFFICE USE ONLY
Affidavit Processed By
Office Location
VS-41 02-13-2015
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