Fillable Amending a Birth Certificate After a Name Change (California)

Fill Online, Printable, Fillable, Blank Amending a Birth Certificate After a Name Change (California) Form

Use Fill to complete blank online CALIFORNIA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Amending a Birth Certificate After a Name Change (California)

On average this form takes 6 minutes to complete

The Amending a Birth Certificate After a Name Change (California) form is 16 pages long and contains:

  • 2 signatures
  • 0 check-boxes
  • 17 other fields

Country of origin: US
File type: PDF

BROWSE CALIFORNIA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
January 2022
Office of Vital Records
Page 1 of 7
Amending a Birth Certificate After a Name Change
Center for Health Statistics and Informatics – Vital Records
Effective January 2022
Introduction
A certified name change order is required to amend (change) the registrant's name.
Use the VS 23 – Amendment of Birth Record to Reflect Court Order Change of Name form to:
Amend a California birth certificate to reflect a registrant’s name change, as granted by:
o A court within California, another state, the District of Columbia, or any territory
of the United States
o Hawaii’s Office of the Lieutenant Governor
• Please see page 7 for a list of frequently asked questions and a
nswers.
• Ple
ase
refe
r to
the Affidavit to Amend a Birth Record pamphlet to:
o Correct spelling errors on the birth certificate
o Add a parent’s court
ordered name change to the child’s birth certificate
o Change both the name and the
sex listed on the
birth certificate to
mat
ch
the
s
ex
i
dentity
• Fo
r
other
a
mendment
ty
pes,
p
lease visit the CDPH-VR website at www.cdph.ca.gov.
What to Submit and Mailing Address
To request an amendment after obtaining a name change, please submit the following:
• Properly Completed VS 23 Form (See form guidelines beginning on page 3.)
• Certified Copy of the Name Change Order (See top section of page 5.)
• Notarized Sworn Statement (Only if requesting authorized copy. See page 6.)
• Appropriate Fee(s) (See bottom section of page 5.)
Mail your packet to the address below:
California Department of Public Health
Vital Records – Amendments – M.S. 5105
P.O. Box 997410
S
acramento, CA 95899-7410
• Amended certificates are returned via standard mail and do n
ot 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 23 - Court Order Name Change Checklist
To assist in the registration of your amendment, please submit the following:
Properly Completed VS 23 Form
The form is completed in black ink and does not contain any alterations or writing in the margins.
Part I matches the current birth certificate, (even if the information is incorrect).
Part II is completely filled out using the information on the court order.
Part II, item 8 contains the full case number, including numbers and letters, (i.e., N1-234).
Part II, item 11 lists the date the judge signed the court order, not the court's filing date.
Part III is completely filled out by the applicant, (the person submitting the application).
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 Obtained a Court Order Name Change
The Certified Copy of the Name Change Order:
Identifies the name listed on the current birth certificate.
Contains an original court seal, not a photocopy. The appearance of the court seal will vary
depending on the court of issuance.
Required if Obtained a Name Change From Hawaii’s Office
of the Lieutenant Governor
The Name Change Order:
Identifies the name listed on the current birth certificate.
Contains both the certification stamp and the Lieutenant Governor’s embossed signature.
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.
For more information visit our website at www.cdph.ca.gov.
January 2022
Page 2 of 7
Amending a Birth Certificate After a Name Change
January 2022
Office of Vital Records
Page 3 of 7
Form Guidelines
To prevent processing delays, please adhere to the following guidelines on how to complete the
Amendment of Birth Record to Reflect Court Order Change of Name (VS 23) form.
General Information
The VS 23 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 23 form.
Part II (General Information)
The general information section must be completely filled out. NOTE: The “Date
of Court Order” is the date the judge signed the order, not the file date.
If the name change order is from Hawaii’s Office of the Lieutenant Governor:
• Name of Court (box 7) must list “Office of the Lieutenant Governor”
• Court Case Number (box 8) must list “Not Applicable” or contain a dash (-).
• County (box 9) must list “Not Applicable” or contain a dash (-).
• Date of Court Order (Box 11) must list the order’s effective date.
Amending a Birth Certificate After a Name Change
January 2022
Office of Vital Records
Page 4 of 7
Form Guidelines (Continued)
Part II (New Name of Individual)
The new name, as changed by the name change order, is listed in this section.
• Separate the new name into first (field 12A), middle (field 12B), and last
(field 12C).
• If any of the fields are meant to be left blank, enter a dash (-).
Part III
Part III must be signed and completed by the applicant.
NOTE: The applicant does not have to be the registrant.
End of form guidelines.
Amending a Birth Certificate After a Name Change
January 2022
Office of Vital Records
Page 5 of 7
Certified Copy of Name Change Order
A certified copy of the Name Change Order is required to change the registrant’s
name, as this certifies the document 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
that 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.
If the name change order is from Hawaii’s Office of the Lieutenant Governor:
• The certified copy of the name change order must contain both the certification
stamp and the Lieutenant Governor’s embossed signature.
• For questions regarding Name Change Orders issued by the State of Hawaii,
please contact the Office of the Lieutenant Governor at 808-586-0255 or visit
https://ltgov.hawaii.gov/
Appropriate Fee(s)
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.
Amending a Birth Certificate After a Name Change
January 2022 Office of Vital Records Page 6 of 7
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
Power of attorney/Executor of the
registrant’s Estate (Include a copy of the
power of attorney or supporting
documentation identifying you as executor.)
Attorney/Licensed Adoption Agency (Under
CA Family Code Section 3140 or 7603)
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.)
Amending a Birth Certificate After a Name Change
Frequently Asked Questions
Q: Where can I find application forms?
A: Application forms, including the Amendment of Birth Record to Reflect Court Order
Change of Name (VS 23) 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: How do I obtain a court order name change?
A: CDPH-VR suggests you contact a family law attorney for legal advice regarding the
name change 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/).
For questions regarding Name Change Orders issued by the State of Hawaii, please
contact the Office of the Lieutenant Governor at 808-586-0255 or visit
https://ltgov.hawaii.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: Amendments become part of the original record, resulting in a multi-page
certificate. You must keep the birth certificate with all amendments attached for
the birth certificate to be valid.
Q: Will my name change order be returned?
A: Documents submitted, including certified copies of name change orders, 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 7 of 7
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)
(Applicant’s Signature)
CERTIFICATE OF ACKNOWLEDGMENT
A notary public or other officer completing this certificate verifies only the identity of the individual
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)
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Amending a Birth Certificate After a Name Change (California)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 14 February 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document