Fillable Correcting a Birth Certificate (Grimes County)

Fill Online, Printable, Fillable, Blank Correcting a Birth Certificate (Grimes County) Form

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

Correcting a Birth Certificate (Grimes County)

On average this form takes 20 minutes to complete

The Correcting a Birth Certificate (Grimes County) form is 5 pages long and contains:

  • 0 signatures
  • 7 check-boxes
  • 75 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Grimes County

BROWSE GRIMES COUNTY (TX) 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
 
Page 1 of 5
VS-170 (Rev. 09/18)
Correcting a Birth Certificate
Who Can Apply for a Correction?
The person named on the birth certificate, if at least 18 years of age.
Parent(s), legal guardian(s), managing conservator, or legal representative (proof required) of the
person named on the certificate.
Hospital or medical facility where the person named on the birth certificate was born.
WHEN SENDING IN THE APPLICATION, PLEASE INCLUDE A PHOTOCOPY OF VALID PHOTO ID(S) FOR THE
PERSON(S) SIGNING SECTION 6. IF THE PERSON NAMED ON THE BIRTH CERTIFICATE IS A MINOR AND
BOTH PARENTS’ NAMES ARE ON THE BIRTH CERTFICATE, BOTH PARENTS MUST SIGN THE APPLICATION
AND SUBMIT A PHOTOCOPY OF EACH PARENT’S VALID ID.
How Do I Make a Correction?
Complete and sign this application. See pages 4 and 5.
Submit the appropriate documentation. See pages 2 and 3.
Submit the appropriate fees. See fee schedule below.
Where Do I Mail the Application?
Regular Mailing Instructions:
Please submit your application, supporting documents (if required) and fees to:
DSHS – Vital Statistics Section, P.O. Box 12040, Austin, TX 78711-2040.
Expedited Service Mailing Instructions:
The order must be sent to the Vital Statistics Section via an overnight mail service such as: FedEx,
Lone Star, or UPS.
Please submit your application, supporting documents (if required) and fees to:
DSHS-Vital Statistics Section, MC 1966, 1100 W. 49
th
Street, Austin, TX 78756.
Fees: How much must I submit?
Fee Schedule Fee
($)
Qty
(#)
Total
($)
Filing Fees (Select one):
O
Correction to Birth Certificate $15.00 =
O
Correction to Birth Certificate by adding/removing/replacing a parent $25.00 =
O
New Birth Certificate based on child’s sex or parent’s race or color
See “Correcting the Child’s Sex or Parent’s Race or Color” on Page 3.
$25.00 =
All orders are returned free of charge by USPS regular mail. For urgent requests, orders
may be EXPEDITED by sending the order through an overnight mail service, such as:
FEDEX, LoneStar, or UPS AND selecting one of the overnight return shipping methods
below.
O
Expedite Overnight Mail (for shipping within USA)
$8 for Overnight Mail + $5 for Expedited processing
$13.00 =
O
USPS Express Mail (for shipping overnight to PO Box ONLY)
$22.95 for Overnight Mail + $5 for Expedited processing
$27.95
=
O
Priority Mail (for shipping to Overseas Military Address ONLY)
$4.95 for Overnight Mail + $5 for Expedited processing
$9.95 =
Birth Certificate(s):
O
Certified Corrected Birth Certificate ($22.00 per copy) $22.00 X =
Grand Total
Fees may be combined in one check or money order made payable to DSHS – Vital Statistics
Visit our website: http://www.dshs.texas.gov/vs/default.shtm (access additional forms, order certified
copies online or visit our frequently asked questions)
Page 2 of 5
VS-170 (Rev. 09/18)
What type of correction are you requesting?
Box # 1: Document Checklist
I want to… You will need one of the supporting
documents shown in Box # 2 below
Correct a hospital error before 1
st
birthday
(hospital must sign and submit application)
No documentation required.
Correct an error or omission made by the hospital after child’s 1
st
birthday
1 or 2
Add or correct child’s first or middle name, BEFORE child’s 1
st
birthday
Examples: Cindie to Cindy or “no name” to Kathie
No documentation required
Add or correct child’s first or middle name, AFTER child’s 1
st
birthday
1, 2, 3, 4, 5, 6, 7, 8, or 9
Correct spelling of child’s last name (all documents must be dated
PRIOR to birth of child)
Example: Martines to Martinez
5, 10, 11, 12, 13, or 14
Correct child’s date of birth, place of birth, time of birth, or sex 1, 2, or 5
Correct parent’s information
(parent must be currently listed on the birth certificate)
5, 10, 11, 12, 13, or 14
Correct mother’s residence address at the time of the child’s birth 1, 2, or 5
Adding a parent AND the parents were married BEFORE the
child was born (Both parents sign Section 6 of this application in
the presence of a notary)
12
Change Legal name Example: Martinez to Brown 5
Remove information from birth record 5
Add/remove/replace a parent See page 3, “Adding, Removing, or
Replacing a Parent’s Name”
Suggested Supporting Documents:
Documents must be original certified copies (no photocopies or notarized copies) on official letterhead or
with an original certification or seal unless otherwise specified below. Foreign documents, including
notaries, must have an apostille or legalization. All supporting documents must match the requested
correction(s) exactly and cannot be altered.
If an item has already been amended once, a court order is required to amend the same item again.
Box # 2: Supporting Documents
1 Hospital or medical record at birth (admission/discharge or worksheet)
2 Letter from Hospital or medical facility explaining correction needed
3 Baptismal certificate - Must be within first 5 years of birth
4 Numident printout from the Social Security Administration (SSA). Issued by the SSA, Office of
Privacy and Disclosure, 617 Altmeyer Bldg., 6401 Security Blvd, Baltimore, MD 21235. Contact
SSA for fees, order form and more information.
5 A certified copy of a court order affecting information shown on the birth certificate.
6 Elementary school record - Must be signed by custodian of school records based on earliest
attendance.
7 Federal census record
8 School census record
9 Armed forces discharge papers (form DD 214) – Photocopy accepted
10 Birth certificate(s) of child’s parent(s)
11 Birth certificate of child’s older brother or sister
12 Certified copy of Parent’s Marriage license
13 Parent’s Naturalization Certificate (must include name change) Call the Immigration and
Naturalization Service (ICE) at 800-375-5283 to obtain information on how to secure this
document.
14 Photocopy of Parent’s domestic passport or Parent’s foreign passport with U.S. Visa
Page 3 of 5
VS-170 (Rev. 09/18)
Adding, Removing or Replacing a Parent’s Name
A new birth certificate may be filed based on parentage to Add, Remove or Replace a parent on the birth
certificate. In addition to this application, one of five types of documentation must be presented as
evidence to file the new birth certificate:
1. A certified copy of the certificate of marriage of the parents;
2. A copy of the Acknowledgment of Paternity (VS-159.1) filed with the Vital Statistics Section;
3. A certified copy of the court decree establishing parentage;
4. A copy of the Acknowledgment of Paternity Rescission (VS 158) filed with the Vital Statistics Section;
or,
5. A gestational agreement.
Box # 3: Adding, Removing or Replacing a parent’s name
I am/We are… You need to complete this application and…
A mother not married during pregnancy and not
married now and wants to add a father
Or
A mother married within 300 days prior to the
birth of the child and wants to add a biological
parent who is not the spouse
(1) Both parents sign Section 6 of this application in
the presence of a notary; and,
(2) Complete an Acknowledgement of Paternity (Visit
the Office of the Attorney General, Paternity
Opportunity Program at
https://www.texasattorneygeneral.gov/cs/establishing-
paternity)
A mother not married during pregnancy but is
now married to the parent
(1) Both parents sign Section 6 of this application in
the presence of a notary; and,
(2) Provide a certified copy of your marriage license
A parent with a court order establishing
parentage / removing parent (only corrections
ordered in the court order will be completed)
Or
Parents with a gestational agreement
(1) One parent signs Section 6 of this application in
the presence of a notary; and,
(2) Provide a certified copy of the entire court order
(all pages) signed by a judge
Parents who have signed a State of Texas
Acknowledgment of Paternity (VS 159.1)
(1) Both parents sign Section 6 of this application in
the presence of a notary; and,
(2) Provide a copy of the signed Acknowledgement of
Paternity (VS-159.1).
A parent who has an Acknowledgement of
Paternity Rescission (VS 158) filed with the Vital
Statistics Section and wants to remove their
name from the birth certificate*
(1) One parent signs Section 6 of this application in
the presence of a notary; and,
(2) Provide a copy of the signed Acknowledgement of
Paternity Rescission (VS-158).
Certified documents submitted will be retained by VSS and placed in a sealed file. A court
order is required to unseal a file. Parents should keep copies of certified documents for their
records and future use before sending them to VSS.
* Once a parent is removed from the birth certificate, they are no longer a qualified applicant to
request a certified copy of the child’s newly corrected birth certificate.
Correcting the Child’s Sex or the Parent’s Race or Color
A new birth certificate may be filed that incorporates the corrected sex of the person named on the birth
certificate. It may also be filed on older records to remove the parent(s) “race or color”. The filing fee to
create a new birth certificate is $25.00. Complete Section 3 and check the bottom box requesting a new
birth certificate be filed. If the bottom box on Section 3 is not checked, the correction will be attached to
the original record as an addendum ($15.00 filing fee required).
Page 4 of 5
VS-170 (Rev. 09/18)
Birth Certificate Correction Application
Type or Print (please use blue or black ink ONLY) Request No.____________
Section 1: What is Your Name? (Applicant’s Information)
Name (First, Middle, Last):
Address (Mailing Address, City, State, Zip):
Email Address: Telephone # (8am-5pm)
( ) -
Your relationship to Person named on the birth certificate: Parent Self Hospital Representative
Legal guardian(s) or Managing Conservator Legal Representative (proof required)
>>>>>>>A COPY OF THE APPLICANT’S VALID PHOTO ID MUST BE ATTACHED<<<<<<<
Section 2: Birth Certificate Information
Enter information as it appears on the current birth certificate.
Birth Certificate Number, if known:
142 - -
Child’s First Name:
Middle Name: Last Name:
Date of Birth: Sex:
Place of Birth (City or town) (County) (State)
TEXAS
Full Maiden Name of Parent 1:
Full Maiden Name of Parent 2:
Section 3: What do you want to correct?
We cannot accept whiteout, strike-through, alterations, or write overs.
List items to be added,
corrected or removed
What is on the birth certificate now? What should the birth certificate
say?
Example: Child’s First Name Not Shown Tara
Example: Date of Birth August 2, 2010 August 12, 2010
Check box (if applicable):  We/I am requesting a new birth certificate be filed to incorporate the
correction to the child’s sex or parent’s race or color.
IMPORTANT: Photocopies, alterations, strike-through, or write overs of
this completed application will not be accepted. Please use a new
application if you make a mistake.
Page 5 of 5
VS-170 (Rev. 09/18)
Section 4: Add or Replace a Parent
If you want to add or replace the name of a parent, please fill out this section.
Full New Name of Child (Even if it will Remain the Same). If changing child’s first or middle
name, birth certificate correction procedures on page 2 apply.
First Name:
Middle Name: Last Name(s): Suffix:
Name of Second Parent
Title to Appear on Birth Record (check one):  Mother  Father  Parent
Full Name (Full Maiden Name Prior to First Marriage)
First Name:
Middle Name: Last Name(s): Suffix:
Date of Birth Place of Birth
Month: / Day: /Year: State or Foreign Country:
Section 5: Would you like to request a birth certificate?
Check one:
 No, I would not like a certified copy of the corrected birth certificate.
 Yes, I would like a certified copy of the corrected birth certificate. Number requested: ________
Short or Long form: ________
Please verify fees and quantity ordered in the fee box on Page 1.
Section 6: Affidavit
Please sign below, where appropriate, in the presence of a notary public. Cross-outs or white-outs will
void your application.
WARNING: The Penalty for knowingly making a false statement in this form can be 2-10 years
in prison and a fine of up to $10,000. (Texas Health and Safety Code, Chapter 195).
Self, Parent 1, Legal Guardian, or Health Information Management (HIM) Director:
Signature: Date:
Address: City: State: Zip:
Notary Public, County Clerk, or other person authorized to administer oaths
Sworn to and subscribed before me, this ______ day of ____________ 20______.
Signature: Date:
[Stamp or Seal]
Printed name and title:
Parent 2 or Legal Guardian 2, if applicable:
Signature: Date:
Address: City: State: Zip:
Notary Public, County Clerk, or other person authorized to administer oaths
Sworn to and subscribed before me, this ______ day of ____________ 20______.
Signature: Date:
[Stamp or Seal]
Printed name and title:
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

Correcting a Birth Certificate (Grimes County)

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 21 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document