AFFIDAVIT FOR CURRENT YEAR CORRECTION
(REVISED 07/2017)
PLEASE ADDRESS ALL CORRESPONDENCE TO THE ADDRESS BELOW.
STATE OFFICE OF VITAL RECORDS1680 PHOENIX BLVD. SUITE 100, ATLANTA, GA 30349 PHONE 404.679.4702
PLEASE PRINT OR TYPE ALL INFORMATION LEGIBLY AND CORRECTLY BELOW.
Section 1: REQUIRED INFORMATION
REQUESTING CORRECTION TO:
Birth Stillbirth/Fetal Death Death Adding Spouse
CURRENT LEGAL NAME OF APPLICANT COMPLETING THE AFFIDAVIT
RELATIONSHIP TO THE INDIVIDUAL NAMED ON THE RECORD (i.e. SELF, MOTHER, FATHER, DAUGHTER, SON, FUNERAL DIRECTOR, ETC.)
CURRENT LEGAL NAME OF THE PERSON ON THE RECORD
PLACE OF BIRTH OR DEATH (FACILITY, CITY, AND COUNTY)
DATE OF BIRTH OR DEATH (MONTH, DAY, AND YEAR)
MOTHER/PARENT 1 NAME PRIOR TO FIRST MARRIAGE (IF LISTED ON RECORD)
FATHER/PARENT 2 NAME PRIOR TO FIRST MARRIAGE (IF LISTED ON RECORD)
INFORMATION SHOWN ON ORIGINAL CERTIFICATE
INFORMATION AS IT SHOULD APPEAR ON AMENDED CERTIFICATE
SIGNATURE OF AFFIANT/RELATIONSHIP
SIGNATURE OF AFFIANT/RELATIONSHIP
ACKNOWLEDGED TO BE TRUE BEFORE ME ON (NOTARY’S SIGNATURE & DATE):
MY TERM EXPIRES ON (DATE):
ID TYPE PRESENTED BY BIRTH MOTHER/PARENT 1
ID TYPE PRESENTED BY FATHER/PARENT 2
ID NUMBER PRESENTED BY BIRTH MOTHER/PARENT 1
ID NUMBER PRESENTED BY FATHER/PARENT 2
PLEASE PLACE THE NOTARY SEAL BELOW.
