AFFIDAVIT TO AMEND A MARRIAGE RECORD
NO ERASURES, WHITEOUTS, PHOTOCOPIES,
OR ALTERATIONS
STATE FILE NUMBER LOCAL REGISTRATION NUMBER
PUBLIC CONFIDENTIAL DECLARED NON-CLERGY
TYPE OR PRINT CLEARLY IN BLACK INK ONLY – THIS AMENDMENT BECOMES A PART OF THE OFFICIAL RECORD
PART I INFORMATION TO LOCATE RECORD—TYPE OR PRINT IN BLACK INK ONLY
INFORMATION
AS IT
APPEARS
ON CURRENT
RECORD
1A. FIRST NAME AS LISTED ON MARRIAGE CERTIFICATE IN FIELD 1A
1B. MIDDLE NAME AS LISTED ON MARRIAGE CERTIFICATE IN FIELD 1B
1C. CURRENT LAST NAME AS LISTED ON MARRIAGE CERTIFICATE FIELD 1C
1D. BIRTH LAST NAME, IF DIFFERENT FROM FIELD 1C
2. DATE OF MARRIAGE—MM/DD/CCYY
3. COUNTY IN WHICH THE LICENSE WAS ISSUED
4A. FIRST NAME AS LISTED ON MARRIAGE CERTIFICATE IN FIELD 12A
4B. MIDDLE NAME AS LISTED ON MARRIAGE CERTIFICATE IN FIELD 12B
4C. CURRENT LAST NAME AS LISTED ON MARRIAGE CERTIFICATE FIELD 12C
4D. BIRTH LAST NAME, IF DIFFERENT FROM FIELD 12C
PART II STATEMENT OF CORRECTIONS TO MARRIAGE RECORD
LIST ONE
ITEM PER
LINE
5. ITEM
NUMBER TO BE
CORRECTED
6. INCORRECT INFORMATION THAT APPEARS ON CURRENT RECORD
7. CORRECTED INFORMATION AS IT SHOULD APPEAR
REASON
FOR
CORRECTION
8.
AFFIDAVITS
AND
SIGNATURES
We, the undersigned, hereby certify under penalty of perjury that we have personal knowledge of the above facts and that the
information given above is true and correct.
9A. SIGNATURE OF FIRST PERSON
9B. PRINTED NAME
9C. TITLE/RELATIONSHIP TO PERSON(S) IN PART I
TWO
PERSONS
MUST SIGN
THIS FORM
TO CORRECT
A MARRIAGE
RECORD
9D. ADDRESS (STREET AND NUMBER, CITY, STATE, ZIP CODE)
9E. DATE SIGNED—MM/DD/CCYY
10A. SIGNATURE OF SECOND PERSON
10B. PRINTED NAME
10C. TITLE/RELATIONSHIP TO PERSON(S) IN PART I
10D. ADDRESS (STREET AND NUMBER, CITY, STATE, ZIP CODE)
10E. DATE SIGNED—MM/DD/CCYY
STATE/LOCAL
REGISTRAR
USE ONLY
11. CDPH - VITAL RECORDS OR LOCAL REGISTRAR
STATE OF CALIFORNIA, DEPARTMENT OF PUBLIC HEALTH, OFFICE OF VITAL RECORDS
FORM VS 24C (REV. 04/20)
________________________________ _______________________________
APPLICATION TO AMEND A MARRIAGE RECORD
TYPE OR PRINT CLEARLY IN BLACK INK ONLY
NO ERASURES, WHITEOUTS, PHOTOCOPIES, OR ALTERATIONS
If an acceptable application to amend the record is registered within one year of the date of the event, there is no processing fee;
however, there is a fee required for a certified copy.
Enclosed is the fee of $_ for a certified copy of the newly amended record.
* * *
____
If an acceptable application to amend the record is registered one year or more after the date of the event, there is a fee for filing
the affidavit, which includes one certified copy. There is a fee for each additional certified copy. Please contact your County Recorder,
County Clerk, or the State Registrar for the current fee, or visit our website at www.cdph.ca.gov.
Enclosed is the fee of $_ for filing the affidavit and one certified copy of the newly amended record.
Enclosed is the fee of $_ for each additional certified copy of the newly amended record.
Printed Name of Applicant Mailing Address of Applicant
For Official Use Only
STATE OF CALIFORNIA, DEPARTMENT OF PUBLIC HEALTH, OFFICE OF VITAL RECORDS
FORM VS 24C (REV. 04/20)
_________
_____
_________
_____________________________________________ _____________________________________________________________
( ___________________________________ _____________________________________________________________Phone )
City, State, ZIP Code
Email Address:
READ INSTRUCTIONS CAREFULLY BEFORE COMPLETING THE FORM
1. A Notarized Sworn Statement is required when requesting a certified authorized copy of the amended certificate. For more
information please visit our website at www.cdph.ca.gov.
2. The original marriage certificate cannot be altered. Corrections are made by completing an Affidavit to Amend a Marriage Record
(VS 24C). This form becomes a part of the original recordtype or print clearly in black ink only. Your certified copy will
include a copy of the original certificate with a copy of this form attached. Both documents must remain together for the certified copy
to be valid.
3. Check the type of record to be corrected: Public, Confidential, Declared, or Non-Clergy.
4. Complete Part I, Items 1A–4D with the information as it appears on the current certificate.
5. Enter the certificate item number(s) to be corrected, either from the original or subsequent amendment, in Part II—Item 5 (Item number
to be corrected). List one item per line.
6. Enter the incorrect information as it appears on the current certificate in the line(s) provided below Item 6 (Incorrect Information That
Appears on Original Certificate). In Item 7, enter the corrected information as it should appear for each item listed in Item 6.
7. Enter the reason for the correction(s) in Item 8.
8. Read the affidavit statement. Two persons who are certifying to the statement of corrections must complete Items 9A through 10E.
9. If changing the date or place of marriage, the person who performed the marriage must sign the affidavit as one of the supporting
affiants. The VS 24C cannot be used to change the identity of either party to the marriage.
10. Do not write in Items 11 or 12. This space is reserved for State or Local Registrar use only.
11. When properly completed and signed by two parties, return the form to either the State or Local Registrar, with a check or money order
payable to the Office of Vital Records. The address of the Office of Vital Records is:
California Department of Public Health
Vital Records - Amendments - MS 5105
P.O. Box 997410
Sacramento, CA 95899-7410
NOTE: For Confidential marriage records, the form and the fee, if applicable, must be sent directly to the County Clerk in the
county where the marriage was performed. Certified copies of Confidential Marriage records may ONLY be obtained from the
County Clerk’s Office.
For Public, Declared, and Non-Clergy marriage records, a certified copy of both the original certificate and the amendment form
may be obtained from the County Recorder in the county where the license was issued, or from the State Registrar.
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