Fillable Add, Remove, or Replace a Parent Listed on (California)

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Add, Remove, or Replace a Parent Listed on (California)

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The Add, Remove, or Replace a Parent Listed on (California) form is 18 pages long and contains:

  • 2 signatures
  • 32 check-boxes
  • 21 other fields

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Add, Remove, or Replace a Parent
Listed on a Birth Record
Center for Health Statistics and Informatics – California Vital Records
Effective January 2022
January 2022 Office of Vital Records Page 1 of 9
Introduction
There are two processes available to change the parents listed on a California Birth
Certificate, (VS 22 and VS 21). To determine which process applies to you, please see below.
VS 22
You may complete the Acknowledgement of Paternity (VS 22 form) process if all
three of the following are true:
You are adding the second parent to the birth certificate
The second parent field is blank on the current birth certificate
Both parents are available to sign the applicable form(s)
VS 21
You must complete the Adjudication of Facts of Parentage (VS 21 form) process if:
You are removing or replacing a parent listed on the current birth certificate.
You are adding a second parent to a blank field on the birth certificate, however
one (or both) of the parents are unavailable to sign.
NOTE: A court order is required for this process.
• To change parent information after an adoption, please see Adoption Pamphlet.
• Please see page 9 for a list of frequently asked questions and answers.
• To correct clerical errors on the birth certificate, please refer to the Affidavit to
Amend a Birth Record pamphlet.
• For other amendment types, please visit the CDPH-VR website at www.cdph.ca.gov.
What to Submit (Mailing address on page 3)
To add the second parent with a VS 22 form, please submit:
• Properly Completed VS 22 Form (See Form Guidelines beginning on page 3.)
• Supporting Documents (See requirements on top section of page 7.)
• Notarized Sworn Statement (Only if requesting authorized copy. See page 8.)
• Appropriate Fee (See requirements on bottom section of page 7.)
To remove, replace, or add the second parent with a VS 21 form, please submit the following:
• Properly Completed VS 21 Form (See Form Guidelines on page 6.)
• Certified Copy of the Court Order (See requirements on middle section of page 7.)
• Appropriate Fee (See requirements on bottom section of page 7.)
• Notarized Sworn Statement (Only if requesting authorized copy. See page 8.)
VS 22 - Acknowledgment of Paternity Checklist
To assist in the registration of your amendment, please submit the following:
Properly Completed VS 22 Form
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The form is completed in black ink and does not contain any alterations.
Part I matches the current birth certificate, even if the information is incorrect.
Part II is filled out to include new parent information. This information is used to create the
new birth certificate.
The child was born on or after January 1, 1995.
REQUIRED: The appropriate box is checked in Part III.
The child was born prior to January 1, 1995.
REQUIRED: There are no checked boxes in Part III.
Fields 15A through 16F are thoroughly completed by both parents.
Required Only if the Child Was Born On or After January 1, 1995
The parents were neither married to each other nor in a State Registered Domestic Partnership
(SRDP) at the time of the child's birth.
REQUIRED: Enclosed is a certified copy of the Voluntary Declaration of Parentage DCSS 0909
(VDOP) form that was filed with the Department of Child Support Services.
Th
-
e parents were married to each other at the time of the child's birth.
R
EQUIRED: Enclosed is a photocopy of the parents' marriage certificate.
The parents were in an SRDP at the time of the child's birth.
REQUIRED: Enclosed is a photocopy of the parents' SRDP declaration.
Payment
I have enclosed a check/money order (payable to CDPH Vital Records) in the amount
of twenty-six dollars ($26) for the registration of the amendment, which includes
one certified copy of the amended certificate.
I would like additional copies of the amended certificate, and I have enclosed a
check/money order (payable to CDPH Vital Records) in the amount of twenty-nine
dollars ($29) per additional copy requested.
Notarized Sworn Statement
I have requested copies of the amended certificate and would like the copies to be authorized copies.
I have enclosed a notarized sworn statement.
Optional Item
Photocopy of child’s birth certificate, if available.
For more information visit our website at
January 2022
www.cdph.ca.gov.
Page 2 of 9
Add, Remove, or Replace a Parent Listed on a Birth Record
January 2022 Office of Vital Records Page 3 of 9
Mailing Address
Mail your packet to the address below:
California Department of Public Health
Vital Records – Amendments – M.S. 5105
P.O. Box 997410
Sacramento, CA 95899-7410
Amended certificates are returned via standard mail and do not contain a
tracking number.
1
You may provide a prepaid self-addressed envelope with your request for
CDPH-VR to use and mail the amended certificate back to you. (Not Required)
VS 22 Form Guidelines
Please adhere to the following guidelines on how to complete the Acknowledgement of
Paternity (VS 22) form to prevent delays in the processing of your request.
General Information
The VS 22 form must:
Be completed in black ink.
Not contain any write-overs, alterations, drawings, accents, or other marks to
indicate pronunciation or to distinguish letters in some way, such as è, ñ, or ç.
Part I
PART I must match the current certificate. This means:
It should show any incorrect information as it appears on the current record.
If any of the information in Part I was previously amended, the changes must
be reflected in Part I of the VS 22 form.
Add, Remove, or Replace a Parent Listed on a Birth Record
January 2022 Office of Vital Records Page 4 of 9
VS 22 Form Guidelines (Continued)
Part II
Part II must be completely filled out to include the second parent’s information.
This is the information that will be used to create the new birth record.
A name change order is required to change the child’s name. For more
information, please see the Amending a Birth Certificate after a Name Change
Pamphlet.
Part III (Three Checkboxes)
The parents must check one of the three boxes. The box that is selected determines
the supporting document that must be submitted, (see top of page 7).
NOTE: Marking a checkbox is not required for children born prior to January 01, 1995.
Part III (Parent Signatures)
Both parents must sign and complete this section. NOTE: If one or both of the
parents is not available to sign, you must complete the Adjudication of Facts of
Parentage (VS 21) form process, (see page 1). End of VS 22 Form Guidelines.
VS 21 - Adjudication of Facts of Parentage Checklist
To assist in the registration of your amendment, please submit the following:
Properly Completed VS 21 Form
The form is completed in black ink and does not contain alterations.
Top section of the form lists payment information, and the name, phone number, and mailing
address of the applicant, (the person submitting the application).
PART I of the form matches the current birth certificate, even if the information is incorrect.
PART II is filled out using the information on the court order. This information is used to create
the new birth certificate and should match any changes ordered by the court.
Items 8A through 8C contain the child's new name, if changed by the court.
Items 9A through 14 reflect updated parent information, as ordered by the court. If a parent is
being removed, fields 9A through 11 may be left blank or contain a dash (-).
Certified Copy of the Court Order
The certified copy of the court order:
Provides the child's name and date of birth, as listed on the current certificate.
Clearly identifies the child’s parents.
IMPORTANT NOTE: If the court order is unclear on the parent and child relationship or
on what changes should be made to the birth certificate, the request will be returned
for clarification.
Contains an original court seal, not a photocopy. The appearance of the court seal will
vary depending on court of issuance.
Payment
I have enclosed a check/money order (payable to CDPH Vital Records) in the
amount of twenty-six dollars ($26) for the registration of the amendment, which
includes one certified copy of the certificate.
I would like additional copies of the amended certificate, and I have enclosed a check/
money order (payable to CDPH Vital Records) in the amount of twenty-nine dollars ($29)
per additional copy requested.
Notarized Sworn Statement
I have requested copies of the amended certificate and would like the copies to be authorized copies.
I have enclosed a notarized sworn statement.
Optional Item
Photocopy of child’s birth certificate, if available.
For more information visit our website at www.cdph.ca.gov.
January 2022
Page 5 of 9
Add, Remove, or Replace a Parent Listed on a Birth Record
January 2022 Office of Vital Records Page 6 of 9
VS 21 Form Guidelines
To prevent processing delays, please adhere to the following guidelines.
General Information
The VS 21 form must:
Be completed in black ink and not contain any write-overs or alterations.
Provide the applicant’s contact information and the total fees submitted.
Part I
PART I must match the current certificate. This means:
It should show any incorrect information as it appears on the current record.
If any of the information in Part I was previously amended, the changes must
be reflected in Part I of the VS 21 form.
Part II
Part II must list the information as it should appear on the new birth
certificate, as ordered by the court. End of VS 21 Form Guidelines.
Add, Remove, or Replace a Parent Listed on a Birth Record
January 2022 Office of Vital Records Page 7 of 9
Supporting Documents Required if Submitting VS 22
The following is only required if the child was born on or after January 1, 1995.
• If the parents were married to each other at the time of the child's birth, please submit
a photocopy of the parents’ marriage certificate.
• If the parents were in a State Registered Domestic Partnership (SRDP) at the time of the
child's birth, please submit a photocopy of the parents’ SRDP Declaration.
• If the parents were neither married to each other nor in an SRDP at the time of the
child's birth, please submit a certified copy of the Voluntary Declaration of Parentage
(VDOP) form that was filed with the California Department of Child Support Services.
o The VDOP may be obtained from the California Department of Child Support
Services by sending your mailing address to askpop@dcss.ca.gov or by obtaining
a copy from your County Department of Child Support Services.
Certified Copy of Court Order Required if Submitting VS 21
A certified copy of the court order establishing parentage is required, as this
certifies the court order submitted is a true copy of what the court has on file.
A “certified” copy of a court order is a photocopy of the original order prepared by the court,
which contains a(n):
Original court seal on the front or back of the certified copy and not on a blank sheet of
paper.
Signature or signature stamp of the judge’s signature.
Signature or signature stamp of the court clerk’s signature.
Appropriate Fee
There is a twenty-six dollar ($26) registration fee, which includes one (1) certified copy of
the amended certificate.
• Additional certified copies are twenty-nine dollars ($29) each.
• Checks or Money Orders must be made payable to CDPH Vital Records.
• International money orders for out-of-country requests must be payable in U.S. dollars.
Add, Remove, or Replace a Parent Listed on a Birth Record
January 2022 Office of Vital Records Page 8 of 9
Notarized Sworn Statement
An authorized person must submit a notarized sworn statement to receive a certified
authorized copy of the amended certificate. Please see list of authorized persons below:
Registrant (Name on Certificate)
Grandparent/Grandchild of
Registrant
Authorized by Court Order (Include
copy of court order.)
Law Enforcement/Govt. Agency
(Conducting Official Business)
Parent/Legal Guardian of Registrant
(Legal guardian must provide
documentation.)
Child/Sibling of Registrant
Spouse/Registered Domestic Partner of
Registrant
Attorney Representing Registrant or
Registrant’s Estate
Attorney/Licensed Adoption Agency (Under
CA Family Code Section 3140 or 7603)
Power of attorney/Executor of the
registrant’s Estate (Include a copy of the
power of attorney or supporting
documentation identifying you as executor.)
The notarized sworn statement must:
Include a penalty of perjury statement
Identify the applicant’s relationship to the registrant
Be signed in the presence of a notary public
Contain the notary’s official seal. (NOTE: A sworn statement notarized by a foreign
notary must have an apostille attached. Foreign notarizations obtained at a United
States Embassy or Consulate do not require an apostille.)
Please see sample sworn statement below. (The notary completes the Certificate of
Acknowledgment section after the applicant’s signature is witnessed.)
Add, Remove, or Replace a Parent Listed on a Birth Record
Frequently Asked Questions
Q: Where can I find application forms?
A: Application forms, including the Adjudication of Facts of Parentage (VS 21) and
Acknowledgment of Paternity/Parentage (VS 22) forms, are located on the CDPH-VR
Vital Records, Data and Statistics Forms webpage.
(https://www.cdph.ca.gov/Programs/PSB/Pages/BirthDeathMarriageCertificates.aspx)
Q: Where can I find informational pamphlets?
A: Informational pamphlets for all amendment types are located on the CDPH-VR Vital
Record Pamphlets webpage.
(https://www.cdph.ca.gov/Programs/CHSI/Pages/Vital-Record-Pamphlets.aspx)
Q: How do I obtain a court order?
A: CDPH-VR suggests you contact a family law attorney for legal advice regarding the
court process. CDPH-VR staff cannot provide legal advice, nor does CDPH-VR have
information about the legal process. You may find helpful court process information
by visiting the court website (http://www.courts.ca.gov/).
Q: What is the current processing time?
A: Current processing times are listed on the CDPH-VR website.
(https://www.cdph.ca.gov/Programs/CHSI/Pages/Vital-Records-Processing-Times.aspx)
Q: Once the amendment is registered, what happens to the birth certificate?
A: The current birth certificate will be sealed and replaced with a new, one-page certificate.
Q: Will my supporting documents be returned?
A: Any supporting documents, including the certified copy of the court order, VDOP
form, or sworn statement, will not be returned once the amendment is
registered. Please keep copies of all documents submitted.
Q: What if I still have questions?
A: Please contact our Customer Service Unit by email at AmendVR@cdph.ca.gov or
telephone at (916) 445-2684.
January 2022 Office of Vital Records Page 9 of 9
State of California – Health and Human Services Agency California Department of Public Health
VS 20 (1/20)
Page 1 of 2
SWORN STATEMENT INSTRUCTIONS
• Only one sworn statement is required for multiple records.
• Sworn statements are not required for informational copy requests.
• Authorized individuals must complete the top portion of the sworn statement by signing and
identifying their relationship to person listed on certificate.
• Sworn statements must be notarized for authorized copy requests. Law enforcement,
governmental agencies, and funeral establishments (death records only) are exempt from the
notary requirement, but must complete the top portion of the sworn statement page.
• A sworn statement notarized by a foreign notary must have an apostille attached. Foreign
notarizations obtained by an Ambassador, Minister, Consul, Vice Consul or Consular Agent of the
United States, or from a Judge of Court of record having a seal in a foreign county do not require
an apostille.
RELATIONSHIP TO REGISTRANT
List of Authorized Persons:
• The registrant or a parent, legal guardian, child, grandparent, grandchild, sibling, spouse, or
domestic partner of the registrant.
• A party entitled to receive the record as a result of court order or an attorney or licensed adoption
agency seeking the birth record in order to comply with the requirements of Section 3140 or
7603 of the Family Code. (Please include a copy of the court order.)
• A member of a law enforcement agency or a representative of another governmental agency, as
provided by law, who is conducting official business. (Companies representing a government
agency must provide authorization from the government agency.)
• Any person or agency empowered by statute or appointed by a court to act on behalf of the
registrant or the registrant’s estate (Include a copy of the power of attorney or documentation
identifying you as executor.)
• An attorney representing the registrant or the registrant’s estate.
• Any agent or employee of a funeral establishment who acts within the course and scope of
employment and on behalf of persons specified in HSC § 7100 (a) (1)-(8).
• Surviving next of kin (As specified in HSC § 7100).
State of California – Health and Human Services Agency California Department of Public Health
VS 20 (1/20)
Page 2 of 2
SWORN STATEMENT
I,
(Applicant’s Printed Name)
, declare under penalty of perjury under the laws of the
State of California, that I am an authorized person, as defined in California Health and Safety Code Section 103526
(c), and am eligible to receive a certified copy of the birth, death, or marriage certificate of the following
individual(s):
, .
Regis
trant
(Name of person whose certificate
you are requesting)
Applicant's Relationship to Registrant
(Must be an authorized person)
,
(The remaining information must be completed in the presence of a Notary Public or CDPH Vital Records staff.)
Subscribed to this
(Day)
day of
(Month)
, 20 , at
(City) (State)
CERTIFICATE OF ACKNOWLEDGMENT
A notary public or other officer completing this certificate verifies only the identity of the individual
who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or
validity of that document.
State of
County of
On before me,
(Insert name and title of the officer)
,
personally appeared
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed
to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their
authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity
upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under
the laws of the State of California that the foregoing paragraph is true and correct
WITNESS my hand and official seal.
(SEAL)
(SIGNATURE OF NOTARY PUBLIC)
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Add, Remove, or Replace a Parent Listed on (California)

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Completed 14 February 2022

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