Fillable Birth Record Amendment Packet

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Birth Record Amendment Packet

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Birth Record Amendment Packet
INSTRUCTIONS, SUPPORTING DOCUMENTS & APPLICATION
INSTRUCTIONS
Use the Birth Record Amendment Application form to add or change information on a Minnesota birth certificate. To
add missing information to a birth record you need to send in at least one supporting document. To change
information on a birth record you must send in at least two supporting documents. You may need to send additional
documentation depending on what items you wish to amend. See What you need to know about supporting
documents on pages 4, 5 and 6 of this document.
"Amendment" means completion or correction made to demographic and legal items on a birth record after purchase
of a birth certificate, or more than one year after the birth, whichever occurs first.
What does the birth certificate show now?
Fill in this section with the information as shown on the birth certificate now. This information helps the Office of Vital
Records locate the correct birth record.
You may request amendments to the following items:
Child’s/Subject’s
▪ First, middle, last name and name suffix
▪ Date of birth
▪ Time of birth
▪ Plurality (single birth, twin birth, triplet, etc.)
▪ Sex
▪ Place of birth
Parent’s
▪ Names (first, middle, last, name suffix – not entire name,
unless ordered by court)
▪ Names at birth (name before first marriage)
▪ Date of birth
▪ Place of birth
What item(s) do you want to amend? How do you want the
information to show on the new certificate?
List each item you want to amend on a separate line in the left column. In the right column, print how you want the item
to show on the new certificate. Your application should look similar to the example below. If the number of items you
want to amend is more than five, see the last page of this document.
Pag
e 2 of 9 OFFICE OF VITAL RECORDS 9/2018
I N S T R U C T I O N S
Requester Information - Information about you - What is your…
…relationship to the subject of the birth record? Only certain individuals may request amendments to birth records. This
is for the protection of the subject of the birth record. Indicate your relationship to the subject of the record.
If you are the subject of the record, you must be 18 or older to request an amendment. If you have a court order and are
18 or older, you must be the requester, not your parent.
If you are a parent, your name must be on the subject’s current birth record.
If you are a legal guardian or legal representative of the subject, you must include a certified copy of a U.S. court order
with the application. The court order must name you as the legal guardian or list you as the legal representative.
Complete the rest of the Requester Information section so that the Office of Vital Records can contact you if we have
questions and so that we can send your documents back to you.
REQUIRED – Sign this application in front of a Notary Public
Do not sign the application until you are in front of a notary public. You must present government-issued photo
identification to the notary. The notary will check your identification, and watch you sign and date the application. Then,
the notary will mark the application with a stamp (or a "seal") and sign the application. The notarized application shows
the Office of Vital Records that you really signed it.
See Notary information (http://www.health.state.mn.us/divs/chs/osr/notary.html)
on the Minnesota Department of
Health website if you want more information.
Birth record amendment fee
You must pay a fee to amend a Minnesota birth record when you apply. The fee for administrative review and
processing of a request for the amendment of any vital record is $40. Fees are non-refundable. Minnesota Statutes,
section 144.226. The $40 fee is only for the amendment. The fee does not include a new birth certificate.
Do you want a new birth certificate after the amendment?
One birth certificate costs $26. Enter $26 in the box showing “Enter $26 for 1 certificate.”
If you want more than one certificate, additional certificates cost $19 each if you order them now on this application.
Enter the number of additional copies in the box showing “Enter # copies.”
Do you want standard or faster processing?
Standard processing means that we process amendment requests in the order that we receive them. If you want
standard processing, enter $0 on the application under ‘Choose processing fee’.
If you want faster processing of the amendment, enter $20 on the application under ‘Choose processing fee’. The $20
fee moves your request ahead of standard requests. Faster processing does not include UPS delivery.
Visit Birth Record Amendments (http://www.health.state.mn.us/divs/chs/osr/amend.html)
or call 651-201-5970 to
check on processing times.
Page 3 of 9 OF
FICE OF VITAL RECORDS 9/2018
I N S T R U C T I O N S
How do you want us to send your documents back to you?
After we complete your request, we will send you your supporting documents and any new certificates you order back
by Regular First Class Mail®.
If you want UPS delivery to an address in the United States, enter $16 on the application under ‘Choose delivery fee’.
Check the box to require a signature for UPS delivery. The Office of Vital Records and UPS are not responsible for
deliveries that do not require a signature.
If you want us to send your documents to an address outside of the United States, you must include a UPS prepaid
envelope when you submit your application, supporting documents and fees.
How do you want to pay?
In this section, mark the box that shows how you will pay for the services you chose. You may pay by credit card, check
or money order. Fees are payable with your application and are non-refundable. The Office of Vital Records will not
process amendments or issue new certificates without the fees.
If you want to pay by credit card, fill in the cardholder name, card number, expiration date (Valid thru) and 3-digit
security number.
If you want to pay by check or money order, make the check or money order payable to the Minnesota Department
of Health. Write your check number or your money order number in the space provided.
Do not send cash.
Send your application, supporting documentation and payment to
the Office of Vital Records
You must send your application, payment and supporting documentation to the address on the Birth Record
Amendment Application. The Office of Vital Records does not have walk-in service.
Mailing Address
Minnesota Department of Health
Central Cashiering – Vital Records
PO Box 64499
St. Paul MN 55164-0499
Courier/FedEx/UPS
Minnesota Department of Health
Office of Vital Records
85 E 7th Place Suite 220
St. Paul, MN 55101
If you have questions about this information, call 651-201-5970 or email health.vitalrecords@state.mn.us
.
Si necesita ayuda en espanol, por favor llame a Jeanett al numero 651-201-5350.
Yog koj tsis muaj peev xwm to taub daim ntawv no thiab xav tau kev pab, thov hu rau 651-201-5970 thiab nug kom tau
ib tus neeg txhais lus.
Haddii aysan kuu suurtogaleynin in aad fahamtid warqadaan oo aad rabi laheyd caawin, fadlan soo wac 651-201-5970
oo weydii turjubaan
Page 4 of 9 OFFICE OF VITAL RECORDS 08/2018
What you need to know about
supporting documents
When you request an amendment to a Minnesota birth record, you must provide documentation to
support additions or changes to items that print on a birth certificate. To add missing information to a
birth record you need to send in at least one supporting document. To change information on a birth
record you must send in at least two supporting documents. You may need to provide more
documents depending on what you want to amend. We will return all of your original documents
when we are finished processing your request. Minnesota Rules, part 4601.1100 lists the
requirements for documents submitted.
Each document must:
1. Show the item you want to add or change exactly as you want it to appear on the birth
certificate, AND
2. Show at least two items that match what is on the birth certificate already that you are not
asking to have changed, AND
Documents must be What does this mean?
Legible Letters and words can be identified; document is sharp – not blurred or smeared
Unmodified No erasures; nothing crossed out; no correction tape or fluid
Original Actual passport or certificate of naturalization (not copies)
Certified
Birth, death or marriage certificates, military discharge forms, and court orders must
be issued by a government office – certified documents usually have a stamp or seal
on them
Authenticated
Copies of hospital records, clinic records, school records, social services records that
are authenticated
Authenticated means an employee from the place giving you the record declares in
writing that the document they are providing you is a true and accurate copy of the
record on file. At minimum, the document must list the name and address of the
organization and be signed and dated by an employee of the organization.
In English
Supporting documentation must be in English or translated into English. A qualified
translator must translate documents in other languages (birth certificates, marriage
certificates, and other records) into English; the translator must sign the translation
in front of a notary public.
Depending on subject’s
age, created within a
certain number of years
from birth OR a certain
number of years before
the request
If the subject is less than 7 years old, the document must be from the subject’s
first year of life OR from at least one year before the date of the amendment
request.
If the subject is seven or more years old, the document must be from before the
subject’s third birthday OR at least seven years before the date on the amendment
request.
INFORMATION ABOUT DOCUMENTS REQUIRED TO AMEND A BIRTH RECORD
Page 5 of 9 OFFICE OF VITAL RECORDS 09/2018
Acceptable supporting documents
Acceptable supporting documents must show the certification item as you want it to print after the
amendment AND at least two items that we can match on the current record before it is changed. We
will accept the documents listed below if they meet all of the requirements above and the information
supports the requested amendment:
▪ Authenticated U.S. school record or official school transcript
▪ Authenticated hospital, clinic or social services record
▪ Valid (unexpired) passport – NOT a notarized photocopy
▪ Original or certified copy of U.S. military discharge papers (such as a DD214 form)
▪ Certified (government issued) copy of a marriage certificate
▪ Certified copy of a U.S. court order
▪ Certified copy of a birth certificate of a child
▪ Certified copy of a birth certificate of a parent or sibling (these can only be used to amend parent
information)
▪ U.S. baptism certificate or other church record with a phone number to the church so the record
may be verified
▪ Original or certified copy of a Certificate of Naturalization AND certified Petition for Name Change
▪ Official tribal enrollment record
▪ Social security number history (Numident) printout from the Social Security Administration Office
▪ Other documents the Office of Vital Records determines are acceptable
Documents NOT Accepted
▪ hospital souvenir birth certificate
▪ driver’s license
▪ state, employee, or other ID card or permit
▪ social security card or statement
▪ application of any kind
▪ insurance card or policy
▪ paycheck stub
▪ tax return
▪ statement or bill
▪ newspaper article
▪ other documents that do not meet all of
the requirements listed above
Gender
There are unique requirements for changing gender.
To change the sex listed on the subject’s birth record, the requester must submit either of the following:
Medical certification of appropriate clinical treatment for gender transition in the form of an original
letter from a licensed physician. The letter must identify the subject using the name and date of
birth on the current birth record.
OR
Certified copy of a court order that specifically directs amendment of the subject's sex on the birth
record.
INFORMATION ABOUT DOCUMENTS REQUIRED TO AMEND A BIRTH RECORD
Page 6 of 9 OFFICE OF VITAL RECORDS 09/2018
Court Orders
Court orders must:
▪ Be certified
▪ Be from a U.S. Court
▪ Show the subject’s name and date of birth as they currently appear on the birth record
▪ Clearly identify which items are to be amended on the birth record
▪ Specifically direct the birth record to be amended in the “it is ordered” section if the parent’s
names are to be changed on the subject’s birth record
For information on getting a Minnesota court order, see the Minnesota Judicial Branch
website.
Court-ordered name change
For the subject of the record
A subject, who has a court order directing a name change on his or her own birth record, must
complete the Birth Record Amendment Application if the subject is 18 years of age or older. The
certified copy of the court order must accompany the amendment application.
If the subject is a minor, a parent must complete the Birth Record Amendment Application for a
court-ordered name change and supply a certified copy of the court order.
If the subject is incapacitated, a parent, guardian, or legal representative must complete the Birth
Record Amendment Application for a court-ordered name change and supply a certified copy of
the court order.
For the parent(s)
A court order to change the names of the parents on a subject’s birth record must:
▪ spell out the parent name(s) before and after the name change
▪ specify that the parents’ names be changed on the child’s birth record, and
▪ if the parents’ names are to be changed on more than one child’s birth record, each child’s name
must be listed
Page 7 of 9 OFFICE OF VITAL RECORDS 09/2018
Birth Record Amendment Application
Use this form to add or change information on a Minnesota birth record. With your application, you must send
documents that support the changes you are requesting.
It is against the law to provide false information to amend a vital record. You may be subject to fines, jail time or both.
Minnesota Statutes, section 144.227 and section 609.02, subdivisions 3 and 4.
What does the birth record show now?
Child/Subject
Child/Subject first name Child/Subject middle name Child/Subject last name Name suffix
(Jr, Sr, II, III, etc.)
Date of birth (MM/DD/YYYY)
☐ Female
☐
Male
City of birth County of birth
Parents
First name Middle name Last name Name before 1
st
marriage
First name Middle name Last name Last name before 1
st
marriage
What item(s) do you want to amend?
List each item separately - see the instruction sheet
How do you want the information to show on the new certificate?
See the instruction sheet
Item to amend Show on new certificate as
Item to amend Show on new certificate as
Item to amend Show on new certificate as
Item to amend Show on new certificate as
Item to amend Show on new certificate as
If you want to amend more items, see the last page of this form.
Requester Information – Information about you — What is your relationship to the subject of the birth record?
☐ I am the subject of the record – you must be 18 or older (if you have a court order, you must be the requester – not your parent)
☐ I am a parent listed on the record
☐ I am a legal guardian or legal representative of the subject (provide a certified copy of a U. S. court order to show this relationship)
Your name (print) Your date of birth (MM/DD/YYYY)
Mailing Address – Street (United Parcel Service (UPS) will not deliver to PO boxes or APO addresses.) Apt/Unit #
City State ZIP Daytime Phone (XXX-XXX-XXXX) Email
REQUIRED – Sign this application in front of a Notary Public
I certify that the information provided on this application is accurate and complete to the best of my knowledge.
If I am not eligible to make amendments to the birth record, the Minnesota Department of Health (MDH) will contact me. I give MDH
permission to apply my payment to a follow up application.
Your (requester’s) signature Notary Stamp/Seal
Sworn to/affirmed before me on day of , 20__________
Printed name of notary public
Notary public signature My commission expires
Page 8 of 9 OFFICE OF VITAL RECORDS 09/2018
Birth Record Amendment Application
Requester Name:
Birth record amendment fee
Amendment fee
The fee for administrative review and processing of a request for the amendment of
any vital record is $40.
$40
Do you want a new birth certificate after the amendment? New birth certificate(s)
One birth certificate is $26
Enter $26 for 1 new certificate or
$0
I want extra copies at $19 each
Enter # copies
Do you want standard or faster processing? Choose processing fee
Standard - request processed in the order received - $0
Enter $0 or $20
Faster - your request goes ahead of standard requests - $20
NOTE: Does not include UPS delivery (see below)
How do you want us to send your documents back to you?
Choose delivery fee
Regular First Class Mail® - $0
Enter $0 or $16
United Parcel Service (UPS) - $16
• For UPS delivery in the United States, check here ☐ to require a signature. The Office of Vital Records and UPS are
not responsible for deliveries that do not require a signature. UPS will not deliver to PO boxes or APO addresses.
• For delivery outside of the United States, you must provide a prepaid UPS envelope.
Fees are payable at the time of application and are non-refundable.
Minnesota Statutes, section 144.226
Total due:
At least $40
How do you want to pay?
☐ Credit card
MasterCard/VISA/Discover
Cardholder name Valid thru MM/YY
Card number 3-digit security code
☐ Check
Check #___________________________
Make your check or money order payable to Minnesota Department
of Health. DO NOT SEND CASH.
Checks returned for non-payment will result in a $30 charge to you. You could
also face civil penalties. Minnesota Statutes, section 604.113, subdivision 2.
☐ Money order
Money order # ______________________________
If you have questions, contact the Office of Vital Records at health.vitalrecords@state.mn.us or 651-201-5970.
Send your application, supporting documentation and payment to the Office of Vital Records:
Mailing address
Minnesota Department of Health
Central Cashiering – Vital Records
PO Box 64499
St. Paul MN 55164-0499
UPS/Courier
Minnesota Department of Health
Office of Vital Records
85 E 7th Place, Suite 220
St. Paul, MN 55101
Enter total if completing by hand
$ 0
$ 40
Page 9 of 9 OFFICE OF VITAL RECORDS 09/2018
Birth Record Amendment Application
Requester Name:
What item(s) do you want to amend?
List each item separately - see the instruction sheet
How do you want the information to show on the new certificate?
See the instruction sheet
Item to amend Show on new certificate as
Item to amend Show on new certificate as
Item to amend Show on new certificate as
Item to amend Show on new certificate as
Item to amend Show on new certificate as
Item to amend Show on new certificate as
Item to amend Show on new certificate as
Item to amend Show on new certificate as
Item to amend Show on new certificate as
Item to amend Show on new certificate as
Item to amend Show on new certificate as
Item to amend Show on new certificate as
Item to amend Show on new certificate as
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Birth Record Amendment Packet

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Completed 29 June 2022

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