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DH 429, 04/2016, Florida Administrative Code 64V-1.002 (Obsoletes Previous Editions)
State of Florida
Department of Health – Office of Vital Statistics
APPLICATION FOR AMENDMENT TO FLORIDA BIRTH RECORD
IMPORTANT: Read the entire application form before completing. TYPE OR PRINT
Requirement for ordering: If you are an eligible applicant, complete and sign this application, state your relationship to registrant and provide a copy of valid photo identification. If you are an attorney
representing an eligible person, you need only sign, provide professional license or bar number, indicate name of person whom you represent and their relationship to the registrant in the appropriate spaces
below. If applicant is not an eligible person, an Affidavit to Release a Birth Certificate, DH Form 1958, must be completed and signed by an eligible person before a notarizing official and submitted in
addition to this application form. Acceptable forms of photo identification are: Driver’s License, State Identification Card, Passport, and/or Military Identification Card.
NAME ON OR FOR
NEW BIRTH RECORD
OF REGISTRANT
FIRST
MIDDLE
LAST
SUFFIX
NAME AS RECORDED
ON CURRENT BIRTH
RECORD
FIRST
MIDDLE
LAST
SUFFIX
DATE OF BIRTH
MONTH
DAY
YEAR (4-DIGIT)
STATE FILE NUMBER (IF KNOWN)
SEX
PLACE OF BIRTH
HOSPITAL
CITY OR TOWN
COUNTY
FLORIDA
MOTHER’S / PARENT’S
NAME
FIRST
MIDDLE
LAST NAME PRIOR TO FIRST MARRIAGE (if applicable)
SUFFIX
FATHER’S / PARENT’S
NAME
FIRST
MIDDLE
LAST NAME PRIOR TO FIRST MARRIAGE (if applicable)
SUFFIX
CHECK TYPE OF AMENDMENT:: Adoption Correction Legal Name Change Paternity Establishment
$20.00 AMENDMENT PROCESSING FEE includes the issuance of ONE certification
FEES ARE NONREFUNDABLE: See information entitled “Fees” on page 2.
Quantity
1
= 1
Amount
$20.00
1
st
additional certification: $9.00
$9.00
X
1
= $9.00
$
Other additional certifications (after the 1
st
additional certification) are $4.00 each.
$4.00
X
=
$
RUSH ORDERS (Optional): $10.00 per order. Envelope must be marked “RUSH”. Yes No
(Refer to information entitled Response Time) $
TOTAL AMOUNT ENCLOSED: Check or money order payable to Vital Statistics in U.S. Dollars (DO NOT SEND CASH)
Florida Law imposes an additional service charge of $15 for dishonored checks. $
APPLICANT/MAILING INFORMATION
Any person who willfully and knowingly provides any false information on a certificate, record or report required by Chapter 382, Florida Statutes, or on any application or
affidavit, or who obtains confidential information from any Vital Record under false or fraudulent purposes, commits a felony of the third degree, punishable as provided in Chapter
775, Florida Statutes.
Applicant’s Name
TYPE OR PRINT
FIRST
MIDDLE
LAST (INCLUDING ANY SUFFIX)
RELATIONSHIP TO
REGISTRANT
DELIVERY ADDRESS (INCLUDE APT. NUMBER, IF APPLICABLE)
CITY
STATE
ZIP CODE
DAYTIME PHONE NUMBER INCLUDING AREA CODE
ALTERNATE PHONE NUMBER INCLUDING AREA CODE
SIGNATURE OF APPLICANT
IF ATTORNEY, PROVIDE BAR/PROFESSIONAL
LICENSE NUMBER
IF ATTORNEY , PROVIDE NAME OF PERSON YOU REPRESENT IIF NOT THE REGISTRANT AND THEIR RELATIONSHIP TO
REGISTRANT
EMAIL ADDRESS
IF THE CERTIFICATION IS TO BE MAILED TO ANOTHER PERSON OR ADDRESS USE THE SPACES BELOW TO SPECIFY SHIP TO NAME AND ADDRESS.
SHIP TO NAME
TYPE OR PRINT
FIRST
MIDDLE
LAST
SUFFIX
HOME PHONE NUMBER
SHIP TO STREET ADDRESS (AND APT.)
WORK PHONE NUMBER
CITY
STATE
ZIP CODE
Print
Clear Form
DH 429, 04/2016, Florida Administrative Code 64V-1.002 (Obsoletes Previous Editions)
INFORMATION AND INSTRUCTIONS FOR AMENDMENT TO BIRTH RECORD APPLICATION
Statute/Rule references may be accessed through the website address at the bottom of this form
FEES: The amendment-processing fee is nonrefundable, even if the amendment cannot be completed. In addition, it can only be applied to this
case and cannot be credited or transferred to another case.
ELIGIBILITY: Pursuant to s. 382.025, Florida Statutes, except for those births occurring over 100 years ago that are not under seal, birth certificates
are confidential and can be issued only to the registrant (the child named on the record) if of legal age (18), parent, guardian, or a legal representative of one
of these persons or by court order. Events occurring over 100 years ago not under seal are public record and available to anyone providing fee and application.
REQUIREMENT FOR ORDERING: If applicant is self, parent or guardian, the applicant must provide a copy of valid photo identification.
If guardian, a copy of appointment order must also be included. If legal representative, your attorney Bar ID number and the name and a notation
of whom you represent must be included with your request. If not one of the above persons, you will need to complete and have notarized the
Affidavit to Release a Birth Certificate, DH Form 1958, and submit with this Application for Amendment to Florida Birth Certificate, DH Form 429,
or provide a court order. A release form is available from this office, most local vital statistics offices within the county health department and our
website. Website address located at bottom of this form.
TYPES OF AMENDMENTS:
A. An amendment resulting from a court ordered action:
Adoption
(for assistance call (904)359-6900, ext.9001)
Legal Name Change
(for assistance call (904)359-6900, ext.9005)
Paternity Establishment
(for assistance call (904)359-6900, ext.9004)
B. An amendment made administratively pursuant to vital statistics law (Chapter 382, F.S) and rule authority (Chapter 64V-1 F.A.C.) (For
assistance call (904)359-6900, ext.9005)
Paternity Acknowledgement
Correction resulting from a misspelling or typographical error or omission
Correction of child’s name
Change to child’s name within 1 year of birth. Note: A legal change of name issued pursuant to s. 68.07(4), Florida Statutes, is required to change the
name after the 1
st
birthday UNLESS supporting documentation can be provided.
C. Putative Father:
This DH 429 form is not used for Putative Father related issues. For more information and assistance please visit our website below or call (904)359-
6900, ext.9001.
Correction to a child’s name resulting from a misspelling or a typographical error can be made at any time after the child’s birth without supporting
documentation.
Omissions of child’s given name(s) may be made up to the child’s 7
th
birthday without supporting documentation.
Corrections to a child’s name (other than misspellings, typographical errors, or omissions) may be made only if documentary evidence supporting the
correction can be provided. In all cases, such changes to a minor child’s name will be made ONLY if both parents named on the birth record (if both are
named) are in agreement and sign the required affidavit before a notarizing official. If both parents are not in agreement or not available to sign, the name
can only be amended by a legal change of name (court order).
See s. 64V-1.002 and .003, Florida Administrative Code, for additional information defining our authority to make corrections to a birth record.
IMPORTANT: IF A NAME HAS BEEN CHANGED PREVIOUSLY ON THE BIRTH RECORD PURSUANT TO A COURT ORDER, I.E., BY ADOPTION,
PATERNITY ACTION OR LEGAL NAME CHANGE, IT CAN ONLY BE CHANGED SUBSEQUENTLY THROUGH ANOTHER COURT ORDER.
RESPONSE TIME: Response time for processing an amendment varies depending upon our workload at the time your request is received. Generally,
an amendment is completed within two to three weeks. RUSH processing is available for those who need assurance of faster service. Orders received in an
envelope marked RUSH and with the $10.00 RUSH fee will be given priority over other pending work; however, no amended certificate can be issued until
all required evidence, forms, applicable fees and appropriate signatures have been received and meet the criteria as established by law or in rules of the
department.
MAIL THIS APPLICATION WITH PAYMENT TO
DEPARTMENT OF HEALTH
OFFICE OF VITAL STATISTICS
ATTN: CORRECTION UNIT
P.O. BOX 210,
Jacksonville, FL 32231-0042
(Street Address: 1217 North Pearl Street, Jacksonville, Florida, 32202)
PLEASE VISIT OUR WEBSITE:
www.FloridaVitalStatisticsOnline.com
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Completed 15 December 2021

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