Fillable APPLICATION FOR AMENDED BIRTH CERTIFICATE BASED ON A (Texas Secretary of State)

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APPLICATION FOR AMENDED BIRTH CERTIFICATE BASED ON A (Texas Secretary of State)

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APPLICATION FOR AMENDED BIRTH CERTIFICATE BASED ON A
COURT ORDERED NAME CHANGE
Budget ZZ 708-153
This form may be used to file a legal name change amendment if submitted with a certified copy of a court ordered name
change.
This form may NOT be used to ADD the father
’s information if the father’s information has been left blank on the
original birth certificate.
This form may NOT be used to REMOVE the father’s information contained on the original birth certificate.
• The fee to file a legal name change amendment is $15.00.
• The additional fee of $22.00 is needed to issue one certified copy of the amended birth certificate.
• The total fee of $37.00 is needed if one copy of the birth certificate is requested after the change is completed.
Mail fee and documents to: Vital Statistics Unit
P.O. Box 12040
Austin, Texas 78711-2040
Toll free telephone number: (888) 963-7111
REQUIRED INFORMATION
Applicants Name:
Mailing Address (street, city, state, zip)
Telephone Email
New Name of Registrant
First Middle Last
Information Currently on the Birth Certificate
1. Full Name of
Registrant
First Name Middle Name Last Name
2. Date of Birth Month Day Year
3. Place of Birth City or Town
County
Gender (Sex)
4. Full Maiden Name of
Mother
First Name Middle Name Maiden Name
5. Full Name of Father First Name Middle Name Last Name
VS 2318.1a Revised 05/2015
WARNING: THIS IS A GOVERNMENTAL DOCUMENT. TEXAS PENAL CODE, SECTION
37.10, SPECIFIES PENALTIES FOR MAKING FALSE ENTRIES OR PROVIDING FALSE
INFORMATION IN THIS DOCUMENT.
State
Full certified copy (original certification) of court order must be sub
mitted.
Page 1 of 3
BLANK
Page 2 of 3
MAIL APPLICATION FOR
BIRTH AND DEATH RECORD
PLEASE PRINT. INCLUDE A PHOTOCOPY OF YOUR VALID ID WHEN SENDING IN THE REQUEST.
Make check or money orders payable to: DSHS - Vital Statistics. All funds are deposited directly to the Texas Comptroller of Public Accounts. For any
search of the files where a record is not found, the searching fee is not refundable or transferable.
Birth Certificates
Death Certificates
Type
Cost X
# of
copies=
Total
Type
# of
copies=
Total
Standard Size Long form
$22
Certified Copy (1 copy)
Heirloom Flag Bassinet
$60
Additional Copies
Total (Check or money order payable to DSHS)
Total (Check or money order payable to DSHS)
I wish to make a voluntary contribution of $5.00 to promote healthy early childhood by supporting the Texas Home Visitation Program
administered by the Office of Early Childhood Coordination of Health and Human Services.
IDENTIFY BIRTH OR DEATH RECORD INFORMATION (Part I)
Full Name of
Person
on Record
First Name
Middle Name
Last Name
Date of Birth/Death
Month
Day
Year
Sex
Place of
Birth/Death
City or Town
County
State
Full Name of
Parent 1
First Name
Middle Name
Maiden Name/Last Name
Full Name of
Parent 2
First Name
Middle Name
Maiden Name/Last Name
APPLICANT INFORMATION (Part II)
Applicant Name
Telephone #
Email Address
Full Mailing Address Street Address City State Zip
Relationship to person listed above
Purpose for obtaining this record:
I authorize mailing to the address below. I have verified that the address below will receive my order.
Name of Person Receiving Copies, if Different from Applicant
Mailing Address for Copies, if Different from Applicant
City
State
Zip
AFFIDAVIT OF PERSONAL KNOWLEDGE (MUST BE SIGNED IN PRESENCE OF A NOTARY PUBLIC) (Part III)
STATE OF COUNTY OF Before me on this day appeared _______________________________________
(Applicant name)
now residing at ____________________________________________________________________________________________________________
(Address) (City) (State)
who is related to the person named on Part I as ___________________________________and who on oath deposes and says that the contents of this
affidavit are true and correct. (Relationship)
The applicant presented the following type and number of identification:
Applicant Signature______________________________________________
Sworn to and subscribed before me, this day of , 20 .
(Seal) Signature of Notary Public and Notary ID Number___________________________________________
Typed or Printed Name: _______________________________________________________________
Commission Expires: ________________________________________________________________
Street Address:_____________________________________________________________________
City, State, Zip:_____________________________________________________________________
WARNING: IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY MAKING A FALSE
STATEMENT ON THIS FORM OR FOR SIGNING A
FORM WHICH CONTAINS A FALSE STATEMENT IS 2 TO 10 YEARS IMPRISONMENT AND
A FINE OF UP TO $10,000. (HEALTH AND SAFETY CODE, CHAPTER 195, SEC. 195.003.
MAIL THIS APPLICATION, PAYMENT AND A VALID PHOTO ID TO:
Texas Vital Records Department of State Health Services
VS-142.3 Rev. 06212016 P.O. Box 12040 Austin, TX 78711-2040
OFFICE USE ONLY
Remit No
By ZZ 708-153
OFFICE USE ONLY
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APPLICATION FOR AMENDED BIRTH CERTIFICATE BASED ON A (Texas Secretary of State)

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Completed 9 March 2021

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