DH 430, 04/2016, Florida Administrative Code Rule 64V-1.002 (Obsoletes Previous Editions)
INSTRUCTIONS – READ CAREFULLY
Any person who willfully and knowingly makes any false statement in a certificate, record, or report required by Chapter
382, Florida Statutes, or in an application for an amendment thereof, commits a felony of the third degree, punishable as
provided in s. 775.084, Florida Statutes.
1. Complete only the upper half of the affidavit. This affidavit will be linked to the original birth certificate thus
becoming part of the birth record. Therefore, when completing, please use black typewriter ribbon or print clearly
using black ink.
a. REGISTRANT’S FULL NAME AT BIRTH – Enter the registrant’s (person for whom the record is filed) name
as it SHOULD APPEAR on the birth certificate.
b. STATE FILE NUMBER – Enter if known, otherwise, leave blank.
c. BIRTH DATE AND BIRTH PLACE – Enter correct date and place of birth of registrant.
d. COLUMN 1 “ITEM OMITTED OR IN ERROR” – List the item(s) in error. Child’s Full Name,
Mother’s/Parent’s Name prior to first marriage (if applicable), Father’s/Parent’s Name prior to first marriage
(if applicable), Date of Birth, etc.
e. COLUMN 2 “BIRTH CERTIFICATE SHOWS” – Enter the information that is currently shown on the birth
certificate.
f. COLUMN 3 “SHOULD BE” – Enter the correct information.
2. Affidavit must be signed by registrant if of legal age of 18 or if not of legal age by parent(s) or legal guardian in the
presence of a notary public. IF CORRECTION IS TO BE REGISTRANT’S NAME AND THE REGISTRANT IS
UNDER THE AGE OF 18, THE AFFIDAVIT MUST BE SIGNED BY BOTH MOTHER/PARENT AND
FATHER/PARENT, BOTH SIGNATURES MUST BE NOTARIZED.
AFFIDAVIT IS NOT ACCEPTABLE IF ERASURES OR ALTERATIONS ARE MADE.
IF ASSISTANCE IS NEEDED IN CONNECTION WITH THIS AMENDMENT, CONTACT THIS OFFICE
AT (904) 359-6900, Ext. 9005.
MAIL THIS APPLICATION WITH PAYMENT AND APPLICATION (DH 429) TO:
DEPARTMENT OF HEALTH
OFFICE OF VITAL STATISTICS
ATTN: CORRECTION UNIT
P.O. BOX 210,
Jacksonville, FL 32231-0042
(Street Address: 1217 North Pearl Street, Jacksonville, Florida, 32202)
PLEASE VISIT OUR WEBSITE:
www.Floridahealth.gov
