Mailing Address Telephone #
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
3. PLACE OF BIRTH
6. FULL NAME OF FATHER
5. STATE FILE NO. (If known)
AFFIDAVIT OF OLDER RELATIVE
PART III. THIS SECTION MUST BE SIGNED BY THE ATTENDING PHYSICIAN, PARENTS, OR AN OLDER BLOOD RELATIVE.
IF CHILD IS A MINOR, BOTH PARENTS MUST SIGN AFFIDAVIT.
Last
8.
LIST ITEM OR ITEM NO.
9. ENTRY ON ORIGINAL CERTIFICATE 10. CORRECT INFORMATION
Signature of Notary Public
Commission Expires
Typed or Printed Name
Street Address
City and State
(8am-5pm)
This section
MUST be signed in the presence of a Notary Public.
STATE OF TEXAS
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.
Signature Signature
Sworn to and subscribed before me, this day of , 20
(Street Address) (City)
(State)
(Name)
Father/Legal Guardian
Mother/Legal Guardian/ Blood Relative, HIM Director
OFFICE USE ONLY
2. DATE OF BIRTH
4. SEX
7. FULL MAIDEN NAME OF MOTHER
PART II. ITEM(S) ON ORIGINAL BIRTH CERTIFICATE TO BE CORRECTED.
IF CORRECTING NAME, PLEASE IDENTIFY THE COMPLETE FIRST, MIDDLE, AND LAST NAME(Type or Print)
STATE OF TEXAS
APPLICATION TO AMEND CERTIFICATE OF BIRTH
NO.
Please submit this application (VS-170), supporting document(s), and the statutory filing fee of $15.
To order a certified copy(s) of the amended record; you will need to complete the attached
application (VS-142.3) and enclose the appropriate fees. Fees can be combined in one check or
money order.
VS-170 REV. 07/2015
WARNING: 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. (HEALTH AND
SAFETY CODE, CHAPTER 195, SEC. 195.003)
NAME __________________________________________________________________________________________________________
First
Middle
___________________________________________
_______________________
__________________________________________________
_____________________________________________________
________________________
_______________
Email Address
____________________________________
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Submit your application and fee(s) to:
VITAL STATISTICS UNIT
DEPARTMENT OF STATE HEALTH
SERVICES
P.O. BOX 12040
AUSTIN, TEXAS 78711-2040
1-888-963-7111
(Seal)l)
1. HOSPITAL RECORD AT BIRTH
2.
BAPTISMAL CERTIFICATE
Must be within fir
st 5 years
of life.
3.
ELEMENTARY SCHOOL RECORD
Must be signed by custodian of
school records based on earliest
attendance.
4. BIRTH CERTIFICATE OF
REGISTRANT’S OLDER
BROTHER OR SISTER
5.
ARMED FORCES DISCHARGE
PAPERS
6. NUMIDENT PRINTOUT from the
Social Security Administration
(SSA) issued by the SSA, Office of
Privacy and Disclosure, 617
Altmeyer Bldg., 6401 Security Blvd,
Baltimore, MD 21235
7.
THE PETITION FOR NATURALIZATION
that includes the name change. Call the
Immigration and Naturalization Service
(ICE) at 800-375-5283 to obtain
information on how to secure this
document.
8.
FEDERAL CENSUS
9.
MARRIAGE RECORD OF PARENTS
A copy of certificate, license, or
application,
whichever
supplies
the
required
facts.
(limited
use)
10.
BIRTH CERTIFICATE(S) OF
REGISTRANT’S PARENT(S)
11.
DIVORCE DECREE (limited use)12.
JUDICIAL ACTIONS
A certified copy of any court action
affecting any information shown on
the birth certificate.
VS-170
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
E. SEX .............................................................................................. Affidavit by medical attendant or affidavit and one document.
Court Order required if change is a result of gender reassignment
surgery.
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)
PART VI. SUGGESTED TYPES OF DOCUMENTARY EVIDENCE. THE CERTIFIED DOCUMENT MUST SHOW THE CORRECT
INFORMATION AND HAVE ORIGINAL CERTIFICATION REGARDING THE ITEM(S) TO BE CORRECTED.
PART V. EXAMPLES OF CORRECTIONS AND TYPES OF DOCUMENTS REQUIRED. GENERALLY, THE AFFIDAVIT AND ONE
NOTE: IF THERE IS NOT AN OLDER RELATIVE, THE PERSON ON THE BIRTH RECORD CAN SIGN, IF ACCOMPANIED BY AN
ACCEPTABLE DOCUMENT.
NOTE: ALL OTHER ITEMS REQUIRING CORRECTION SHOULD BE REFERRED TO VITAL STATISTICS FOR
INSTRUCTIONS ON DOCUMENTATION.
NOTE: FOREIGN DOCUMENTS, INCLUDING NOTARIES - MUST HAVE APOSTILLE OR LEGALIZATION
NOTE: IF THIS IS A HOSPITAL CORRECTION, THEN ONLY THE HIM DIRECTOR CAN SIGN THE AFFIDAVIT.
SCHOOL CENSUS
13.
EXPEDITED SERVICES:
Orders must be sent to the Texas Department of State Health Services via an overnight mail service
such as: Fedex, Lone Star Overnight, or UPS.
ADDITIONAL $5 CHARGE FOR EXPEDITED REQUESTS.
$8 RETURN DELIVERY FOR LONESTAR (within Texas) OR FEDEX (outside of Texas)
$19.95 FOR P.O. BOX AND EXPRESS MAIL (optional)
MAILING ADDRESS FOR EXPEDITED SERVICE:
VITAL STATISTICS UNIT
1100 W. 49TH STREET
AUSTIN, TX 78756
NOTE: ALL SUPPORTING DOCUMENTS MUST MATCH THE REQUESTED CORRECTION(S) EXACTLY.
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MAIL APPLICATION FOR
BIRTH AND DEATH RECORD
PLEASE PRINT. INCLUDE A PHOTOCOPY OF YOUR VALID ID WHEN SENDING IN THE REQUEST.
Make check or money orders payable to: DSHS - Vital Statistics. All funds are deposited directly to the Texas Comptroller of Public Accounts. For any
search of the files where a record is not found, the searching fee is not refundable or transferable.
Birth Certificates
Death Certificates
Type
Cost X
# of
copies=
Total
Cost X
# of
copies=
Total
Standard Size Long form
$22
$20
Heirloom Flag Bassinet
$60
$3
Total (Check or money order payable to DSHS)
Total (Check or money order payable to DSHS)
I wish to make a voluntary contribution of $5.00 to promote healthy early childhood by supporting the Texas Home Visitation Program
administered by the Office of Early Childhood Coordination of Health and Human Services.
IDENTIFY BIRTH OR DEATH RECORD INFORMATION (Part I)
Full Name of
Person
on Record
Middle Name
Last Name
Date of Birth/Death
Day
Year
Sex
Place of
Birth/Death
City or Town
County
State
Full Name of
Parent 1
Middle Name
Maiden Name/Last Name
Full Name of
Parent 2
First Name
Middle Name
Maiden Name/Last Name
APPLICANT INFORMATION (Part II)
Applicant Name
Telephone #
Email Address
Full Mailing Address Street Address City State Zip
Relationship to person listed above
Purpose for obtaining this record:
I authorize mailing to the address below. I have verified that the address below will receive my order.
Name of Person Receiving Copies, if Different from Applicant
Mailing Address for Copies, if Different from Applicant
City
State
Zip
AFFIDAVIT OF PERSONAL KNOWLEDGE (MUST BE SIGNED IN PRESENCE OF A NOTARY PUBLIC) (Part III)
STATE OF COUNTY OF Before me on this day appeared _______________________________________
(Applicant name)
now residing at ____________________________________________________________________________________________________________
(Address) (City) (State)
who is related to the person named on Part I as ___________________________________and who on oath deposes and says that the contents of this
affidavit are true and correct. (Relationship)
The applicant presented the following type and number of identification:
Applicant Signature______________________________________________
Sworn to and subscribed before me, this day of , 20 .
(Seal) Signature of Notary Public and Notary ID Number___________________________________________
Typed or Printed Name: _______________________________________________________________
Commission Expires: ________________________________________________________________
Street Address:_____________________________________________________________________
City, State, Zip:_____________________________________________________________________
WARNING: IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY MAKING A FALSE
STATEMENT ON THIS FORM OR FOR SIGNING A
FORM WHICH CONTAINS A FALSE STATEMENT IS 2 TO 10 YEARS IMPRISONMENT AND
A FINE OF UP TO $10,000. (HEALTH AND SAFETY CODE, CHAPTER 195, SEC. 195.003.
MAIL THIS APPLICATION, PAYMENT AND A VALID PHOTO ID TO:
Texas Vital Records Department of State Health Services
VS-142.3 Rev. 06212016 P.O. Box 12040 Austin, TX 78711-2040
OFFICE USE ONLY
Remit No
By ZZ 708-153
OFFICE USE ONLY
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