North Carolina Department of Health and Human Services
Division of Public Health • N.C. Vital Records
http://vitalrecords.nc.gov/vitalrecords
Mail: 1903 Mail Service Center Location: 225 North McDowell St.
Raleigh, NC 27699-1900 Raleigh, NC 27603-1382
Request to Amend a Record
PLEASE CHECK THE APPROPRIATE BOX: BIRTH DEATH
To begin the process to change a record, mail this form to N.C. Vital Records, 1903 Mail Service Center, Raleigh, NC 27699-1900 along with a certied
check or money order payable to N.C. Vital Records for the $24 (non-refundable) search fee. Personal checks are not accepted. If you need to rush the
processing of this request include an additional $15 (non-refundable) fee and write “EXPEDITE” on the front of the envelope or make an appointment
for walk-in service which also requires an expedite fee. Expedited mail requests will be processed within 15 business days of receipt (please allow for
additional mailing time). After we receive this form we will evaluate your request and respond in writing with further instructions that may include the
following requirements: (1) supporting evidence of the requested change, (2) an ofcial amendment application form to be signed in the presence of a
notary public, and (3) a non-refundable amendment processing fee. Completion of this form does not authorize N.C. Vital Records to change the
birth or death certicate. This form only allows a request to be made.
If you are requesting an appointment or if you have other questions, please call the North Carolina Vital Records Amendments ofce at
(919) 792-5986 prior to completing this application.
ID OF THE PERSON REQUESTING THE AMENDMENT IS REQUIRED. See Page 2 for a list of acceptable IDs.
Requests that do not include proper identication will be returned.
TYPE OR PRINT CLEARLY
PART I – INFORMATION TO LOCATE RECORD
Name at Birth or Death ________________________________________________________________________________________
First Middle Last
Female Male ____________________________________ ________________________________________
Date of Birth or Date of Death County of Birth or County of Death
Were parents married at time of birth? Yes No Did parents marry after the birth of the child? Yes No
Father/Parent ________________________________________________________________________________________________
First Middle Last If applies, Last Name Prior to First Marriage
Mother/Parent ________________________________________________________________________________________________
First Middle Last If applies, Last Name Prior to First Marriage
PART II – STATEMENT OF CORRECTIONS TO BIRTH OR DEATH RECORD
INCORRECT INFORMATION
THAT APPEARS ON THE CERTIFICATE
CORRECTED INFORMATION
AS IT SHOULD APPEAR
N.C. Vital Records (08/2019)
REASON FOR CORRECTION __________________________________________________________________________________
____________________________________________________________________________________________________________
I hereby certify that all the above information is true to the best of my knowledge. Note: It is a felony violation of North Carolina
Law (G.S. 130A-26) to make a false statement on this application.
_____________________________________________________________________ ___________________________________
Signature of Person Applying for Correction(s) Date
____________________________________________________________________________________________________________
Street Address or Post Ofce Box City State Zip Code
_____________________________________________________________________ ___________________________________
Relationship of Person Applying for Correction(s) (Area Code) Telephone Number
