Fill - Free fillable Affidavit to Amend a Birth Record (California) PDF form

January 2022 Office of Vital Records Page 1 of 11

Affidavit to Amend a Birth Record

Center for Health Statistics and Informatics – California Vital Records

Effective January 2022

Introduction

Use the VS

24 - Affidavit to Amend a

Record

form to:

 C

t spelling errors

 Add the child’s first, middle,

r last name to blank fields

 C

t the sex field, date, time, or place of birth of the child

 Change the sex listed to match the sex identity

 Add a parent’s new name after a court ordered name change

 Correct parents’ place or date of birth

 Correct typographical or spelling errors for parents’ name

• Please see page 11 for a list of frequently asked questions and answers.

• To change or add to the name currently listed for the child, please refer to the

Amending a Birth Certificate After a Court Order Name Change Pamphlet.

• To add, remove, or replace a parent listed on the birth certificate, please review the

Acknowledgment of Paternity/Parentage and Adjudication of Parentage webpages.

• For other amendment types,

please visit the CDPH-VR website at www.cdph.ca.gov.

What to Submit and Mailing Address

To request an amendment, please submit the following:

• Properly Completed VS 24 Form (See Form Guidelines beginning on page 4.)

• Notarized Sworn Statement (Only if requesting authorized copy. See page 9.)

• Appropriate Fee (See top of page 10.)

• Supporting Documentation (See bottom of page 10.)

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.

 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 24 - Affidavit to Amend a Birth Record Checklist

To assist in the registration of your amendment, please submit the following:

Properly Completed VS 24 Form

The form is completed in black ink and does not contain alterations or writing in the margins.

Part I matches the current birth certificate, even if the information is incorrect.

Part II, column 8 lists the current birth certificate’s item number that needs correction.

Part II, column 9 lists the incorrect information as it appears on the current birth certificate.

Part II, column 10 lists the correct information as it should appear on the amended certificate.

Part II, item 11 lists a reason for correction.

REQUIRED: If correcting hospital error, item 11 states: "To correct hospital error."

Fields 12A through 13E are completely filled out with proper signatures.

REQUIRED: If correcting hospital error, affidavit contains the signature of a hospital

representative.

The parent obtained a court order name change and is adding an AKA to the child’s certificate.

REQUIRED: Column 10 contains the word 'AKA' before the parent’s new name, (i.e., AKA Smith).

Item 11 states: “Adding AKA to reflect court order name change for parent, case number ###.” Or

“Adding AKA to reflect name change through the naturalization process.”

The back of the form (or second page if printed) lists payment information, and the name,

phone number, and mailing address of the applicant, (person submitting the application).

Supporting Documentation

I am correcting a typographical error on the name, date, or place of birth of child’s parent.

REQUIRED: Included is a photocopy of the parent’s birth certificate, translated to English if

necessary.

I am adding the child's name to blank fields or correcting a typographical error on the name.

PREFERRED: Included is a photocopy of the child's social security card (number can be blacked

out), ID, or passport showing correct spelling of the name.

The parent obtained a court order name change and is adding an AKA to the child’s certificate.

REQUIRED: Included is a certified copy of the parent’s court order name change, or parent’s

photocopy of the Petition for Name Change form from the Department of Homeland Security

and a photocopy of the naturalization certificate.

I enclosed a photocopy of the child's birth certificate. (Submit if available.)

Payment

I am submitting the amendment WITHIN ONE (1) YEAR of child’s birth:

There is no fee to register the amendment and I do not want a copy of the amended certificate.

I would like a copy 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 copy.

I am submitting the amendment ONE (1) YEAR OR MORE AFTER the child’s birth:

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 would like an authorized copy of the amended certificate, and I have enclosed a notarized

sworn statement.

For more information visit our website at www.cdph.ca.gov. January 2022

Page 2 of 11

VS 24 - Affidavit to Correct Sex Field on a Birth Record Checklist

To assist in the registration of your amendment, please submit the following:

Properly Completed VS 24 Form

The form is completed in black ink and does not contain alterations or writing in the margins.

Part I matches the current birth certificate, even if the information is incorrect.

Part II, column 8 lists the current birth certificate’s item number that needs correction.

Part II, column 9 lists the incorrect information as it appears on the current birth certificate.

Part II, column 10 lists the correct information as it should appear on the birth certificate.

Part II, item 11 lists the reason for correction as: "To correct hospital error," or “To correct

Local Registrar error,” depending on agency that made the error.

The physician, birthing hospital administrator, or representative of the Local Registrar

completed items 12A through 12E of the form, depending on the agency that made the error.

The registrant, parent, and/or guardian completed items 13A through 13E of the form.

The back of the form (or second page if printed) lists payment information, and the name,

phone number, and mailing address of the applicant, (person submitting the application).

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 birth 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 would like an authorized copy of the amended certificate and have enclosed a notarized sworn

statement.

Optional Item

Photocopy of current birth certificate, if available.

For more information visit our website at www.cdph.ca.gov.

January 2022

Page 3 of 11

Affidavit to Amend a Birth Record

January 2022 Office of Vital Records Page 4 of 11

Form Guidelines

Please adhere to the following guidelines on how to complete the Affidavit to

Amend a Record (VS 24) form to prevent delays in processing your request.

General Information

The VS 24 form must:

 Be completed legibly in black ink using the 26 alphabetical characters of the

English language.

 Not contain any write-overs, whiteouts, alterations, drawings, symbols,

accents, or other marks to indicate pronunciation or to distinguish letters in

some way, such as è, ñ, ē, 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 24 form.

Part II (Column 8)

PART II Column 8 must list the certificate item number that needs correction.

NOTE: This is the number located on the top left corner of the box being corrected

on the birth certificate.

changing the sex listed on the birth certificate to match the sex identity,

please go to page 8.

Affidavit to Amend a Birth Record

January 2022 Office of Vital Records Page 5 of 11

Form Guidelines (Continued)

Part II (Column 9)

Part II Column 9 must list the incorrect information as it appears on the current

birth certificate.

Part II (Column 10)

Part II Column 10 must list the correct information as it should appear on the

birth certificate.

A parent’s court ordered name change or name change that occurred during the

naturalization process is added as an AKA (“also known as”) to the child’s birth

certificate. See sample above.

Reason for Correction (Box 11)

Box 11 must contain a reason for correction. Please see requirements below

when correcting a hospital error, Local Registrar error, or adding a parent’s AKA:

 If correcting the sex field, date, time, or place of birth of the child due to a

hospital error, the reason for correction must state “To correct hospital

error.”

 If correcting the sex field, date, time, or place of birth of the child due to a

Local Registrar error, the reason for correction must state “To correct Local

Registrar error.”

 If adding a parent’s AKA after a court order name change, include the court

name, date, and case number in reason for correction. See sample above.

If changing the sex listed on the birth certificate to match the sex identity,

please go to page 8.

Affidavit to Amend a Birth Record

January 2022 Office of Vital Records Page 6 of 11

Form Guidelines (Continued)

Affidavit and Signatures

Two people with knowledge of the facts must sign and complete the Affidavit

and Signatures section. Please see requirements below when correcting a hospital

error, Local Registrar Error, or correcting the sex listed on the birth certificate:

 If correcting the date, time, or place of birth of the child due to a hospital

error, at least one of the signers must be a hospital representative.

 If correcting the date, time, or place of birth of the child due to a Local

Registrar error, at least one of the signers must be a Local Registrar

representative.

 If correcting the sex listed on the birth certificate due to a hospital or Local

Registrar error, at least one of the signers must be a hospital or Local Registrar

representative. The second signer may be one of the following:

o The registrant

o The registrant’s parent, legal guardian, or conservator

If changing the sex listed on the birth certificate to match the sex identity,

please go to page 8.

End of Form Guidelines.

VS 24 - Affidavit to Change the Sex on a Birth Record Checklist

To assist in the registration of your amendment, please submit the following:

Properly Completed VS 24 Form

The form is completed in black ink and does not contain alterations or writing in the margins.

Part I matches the current birth certificate, even if the information is incorrect.

Part II, column 8 lists the current birth certificate’s item number that needs correction.

Part II, column 9 lists the incorrect information as it appears on the current birth certificate.

Part II, column 10 lists the correct information as it should appear on the amended certificate.

I do not have a court order to change the sex listed on my birth certificate.

REQUIRED: Part II, item 11 states the reason for correction as: "To match the sex specified

on my birth certificate to my sex identity, and not for any fraudulent purposes."

I have a court order to change the sex (and/or name) on my birth certificate.

REQUIRED: Part II, item 11 states the change(s) being made and provides the court case

number, (i.e., "To change my sex and name based on court order case number 1234").

I, the registrant, completed items 12A through 12E on the form. Only one signature is

required.

The back of the form (or second page if printed) lists payment information, and the name,

phone number, and mailing address of the applicant, (person submitting the application).

Required if Using a Court Order to Change Birth Certificate

The Certified Copy of the Court Order:

Contains an original court seal, not a photocopy. The appearance of the court seal will

vary depending on the court of issuance.

States the name listed on the current birth certificate and, if changing the name, lists what the

name is being changed to.

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 ($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 current birth certificate, if available.

For more information visit our website at www.cdph.ca.gov.

January 2022

Page 7 of 11

Affidavit to Amend a Birth Record

January 2022 Office of Vital Records Page 8 of 11

Change Sex Field to Match Sex Identity Guidelines

The following guidelines apply only if changing the sex listed on the birth certificate to match

the sex identity. NOTE: Part I must match the current birth certificate, as outlined on page 4.

Part II (Columns 8, 9, and 10)

 PART II Column 8 must list the certificate item number that needs correction.

 Part II Column 9 must list the incorrect information as it appears on the

current birth certificate.

 Part II Column 10 must list the correct information as it should appear on the

birth certificate.

The registrant’s name may be changed to reflect a court ordered name change

on the same VS 24 form used to change the sex field. See sample above.

Reason for Correction (Box 11)

Box 11 must contain a self-attestation that states: To match the sex specified on

my birth certificate to my sex identity and not for any fraudulent purposes.

If changing the registrant’s name at the same time the sex field is being

changed, include the court name, date, and case number in reason for

correction. See sample above.

Affidavits and Signatures

Only the registrant’s signature is required in the Affidavit and Signatures

section. Two signatures are not required. End of Form Guidelines.

Affidavit to Amend a Birth Record

January 2022 Office of Vital Records Page 9 of 11

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.)

Affidavit to Amend a Birth Record

January 2022 Office of Vital Records Page 10 of 11

Appropriate Fee

If Amending the Birth Record Within One (1) Year of Date of Birth:

• There is no fee to register the amendment, however a certified copy of the certificate

will not be issued.

• The fee for each certified copy of the amended record is twenty-nine dollars ($29).

There is no fee to register the amendment, but you must pay a fee to receive a certified

copy of the amended record.

• Checks or Money Orders must be made payable to CDPH Vital Records.

There is a twenty-six dollar ($26) fee to correct the sex field due to a hospital or

Local Registrar error if it will result in a corrected one-page certificate.

If Amending the Birth Record One (1) Year or More From Date of Birth:

• 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.

Supporting Documentation

There are specific requirements for some type of requests. Please submit any applicable

documents listed below:

 If adding a parent’s name change as an AKA, please submit one of the following:

o Certified copy of the parent’s court order name change.

o Petition for Name Change from the U.S. Citizenship and Immigration Services

and Certificate of Naturalization with the Department of Homeland Security seal.

 If correcting a parent’s date of birth, place of birth, or a spelling/typographical error to

the parent’s name, please submit a photocopy of the parent’s birth certificate.

 If changing the registrant’s name at the same time the sex field is being changed to

match the sex identity, please submit a certified copy of the court order name change

that contains a(n):

 Original court seal. This authenticating court seal cannot be a photocopy.

 Signature or stamp of the judge’s signature.

 Signature/stamp of the court clerk’s signature.

Affidavit to Amend a Birth Record

January 2022

Office of Vital Records

Page 11 of 11

Frequently Asked Questions

Q: Where can I find application forms?

A: Application forms, including the Affidavit to Amend a Record (VS 24) form, 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: What is the current processing time?

A: Current processing times are listed on the CDPH-VR Processing Times webpage.

(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: Amendments become part of the original certificate, resulting in a multi-page certificate.

You must keep the birth certificate with all amendments attached for the birth certificate

to be valid.

• Changing the sex listed on the birth certificate to match the sex identity will

always result in a corrected one-page certificate.

• Correcting the sex field after a hospital or Local Registrar error will result in a

corrected one-page certificate when requested by the registrant, or the

registrant’s parent, legal guardian, or conservator.

Q: Will my supporting documents be returned?

A: Supporting documents, including sworn statements and courts orders, are not 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.

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

(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)

(Applicant’s Signature)

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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