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Get TX VS-170 2019

00 for each copy of the amended certificate requested. APPLICATION TO AMEND CERTIFICATE OF BIRTH STATE OF TEXAS NO. VITAL STATISTICS UNIT DEPARTMENT OF STATE HEALTH SERVICES P O BOX 12040 AUSTIN TEXAS 78711-2040 1-888-963-7111 This application supporting document s and the statutory filing fee of 15. 00 should be submitted to This fee does not include the cost of a certified copy of the record after the amendment is filed* Please enclose the additional fee of 22. Name Last First Middle Street Address Telephone 8am-5pm 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. City State Zip Code Signature PART I. ENTER INFORMATION AS IT APPEARS ON THE ORIGINAL BIRTH CERTIFICATE* IF THE CHILD S NAME DOES NOT APPEAR ON BIRTH CERTIFICATE ENTER NOT SHOWN IN THE FIRST ITEM. Type or Print 1. FULL NAME OF CHILD 2. DATE OF BIRTH 3. PLACE OF BIRTH 4. SEX 5. STATE FILE NO. If known 6. FULL NAME OF FATHER 7. FULL MAIDEN NAME OF MOTHER PART II. ITEM S ON ORIGINAL BIRTH CERTIFICATE TO BE CORRECTED. Type or Print 8. ITEM OR ITEM NO. 9. ENTRY ON ORIGINAL CERTIFICATE 10. CORRECT INFORMATION AFFIDAVIT OF OLDER RELATIVE PART III. THIS SECTION MUST BE SIGNED BY THE ATTENDING PHYSICIAN PARENTS AN OLDER SISTER OR BROTHER* IF CHILD IS A MINOR BOTH PARENTS MUST SIGN AFFIDAVIT. This section MUST be signed in the presence of a Notary Public* COUNTY OF Before me on this day appeared now residing at who is related to the person named in Item I above as and who on oath deposes and says that the birth certificate identified in Part I is in error with respect to the entries shown in Item 9 above and that the information shown in Item 10 is true and correct. Father/Legal Guardian WARNING Sworn to and subscribed before me this day of Signature of Notary Public Commission Expires VS-170 REV. 12/2005 OFFICE USE ONLY Typed or Printed Name City and State PART V. EXAMPLES OF CORRECTIONS AND TYPES OF DOCUMENTS REQUIRED. GENERALLY THE AFFIDAVIT AND ONE ACCEPTABLE DOCUMENT ARE SUFFICIENT. TYPES OF DOCUMENTS A. ADDING INFORMATION Items left blank on original certificate 1 children 17 and under. affidavit signed by both parents 2 adults 18 and over. affidavit by older relative B. CORRECTIONS IN SPELLING Names having the same sound. affidavit by parent s or older relative C. FIRST OR MIDDLE NAME. affidavit and one document see 1 2 under A D. SIGNIFICANT CHANGE IN LAST NAME. a certified court order SEX. certification by medical attendant or affidavit and one document NAME OF FATHER Refer to examples listed under name unless item is left blank 1 To add information when item is left blank. a paternity determination this form cannot be used to add father s name contact Vital Statistics ALL OTHER ITEMS REQUIRING CORRECTION SHOULD BE REFERRED TO VITAL STATISTICS FOR INSTRUCTIONS ON DOCUMENTATION* PART VI. SUGGESTED TYPES OF DOCUMENTARY EVIDENCE* THE CERTIFIED DOCUMENT MUST SHOW THE CORRECT INFORMATION REGARDING THE ITEM S TO BE CORRECTED.

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