Applicant Affidavit in Support of Amendment of a Birth Certificate Following
Medical Intervention for the Purpose of Sex Reassignment
Registry of Vital Records and Statistics
Massachusetts Department of Public Health
on existing
birth
certificate
Sex:
Male
Female
Name:
to appear on
amended birth
certificate
Sex:
Male
Female
contact
information
affidavit
I have completed medical intervention for the purpose of permanent sex reassignment and am not of the sex
recorded at the time of my birth. I hereby request a permanent amendment of my birth certificate registered in
Massachusetts to reflect my accurate name and sex, as listed above.
In addition to this Affidavit, I am also submitting:
A notarized “Physician’s Statement in Support of Amendment of a Birth Certificate Following Medical
Intervention for the Purpose of Sex Reassignment;”
A court-certified copy of my legal name change decree (if applicable); and
A check or money order, payable to the Commonwealth of Massachusetts, as follows:
$50.00 amendment fee, plus either:
By mail: $32.00 per certified copy for ________ copies
Or, in-person: $20.00 per certified copy for ________ copies
I declare under the pains and penalties of perjury that the information above is true and accurate and that by
signing this document I am authorizing a permanent change to my birth certificate.
information or
to apply
An application for amendment may be submitted by mail or by making an appointment at the Registry of Vital
Records and Statistics. By mail, please include all required documents and fees and send your request to:
Registry of Vital Records and Statistics
Attn: Amendments
150 Mt. Vernon Street, 1
st
Floor
Dorchester, MA 02125
For more information or to make an appointment, telephone: (617) 740-2600 or email:
Vital.Regulation@state.ma.us
.
Amendments also may be made at the Clerk’s Office in the city or town of birth. Fees for amendments and
certified copies vary by community.
