Download Affidavit to Correct a Birth Certificate for Free

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AFFIDAVIT TO CORRECT A BIRTH CERTIFICATE
STATE OF ____________________________________ COUNTY ____________________________
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INFORMATION AS IT APPEARS ON THE ORIGINAL BIRTH CERTIFICATE
Name as Recorded __________________________________________________________________
Date of Birth _____________________________________________________________________
Place of Birth ___________________________________________________________________
Father's Name _____________________________________________________________________
Mother's Maiden Name _________________________________________________________________________
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ITEMS TO BE CORRECTED OR ADDED
_________________________________ Should Read _________________________________
_________________________________ Should Read _________________________________
_________________________________ Should Read _________________________________
_________________________________ Should Read _________________________________
_________________________________ Should Read _________________________________
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FOLLOWING AFFIDAVIT IS TO BE COMPLETED BY THE PERSON WHOSE BIRTH CERTIFICATE IS TO BE
CORRECTED:
I _______________________________________________________ , born _______________________________
(Date of Birth)
and residing at __________________________________________________________________________________
being first duly sworn, say that to the best of my knowledge the foregoing facts are true and correct.
Signature ___________________________________________________________________
Date Signed __________________________________________________________________
SIGNATURE OF NOTARY PUBLIC ______________________________________________
Commission Expires ___________________________________________________________
Notary Seal Submit To:
CUSTOMER SERVICE
VITAL REGISTRATION
ROOM 165
350 CAPITOL STREET
CHARLESTON, WV
25301-
3701
Affidavit to Correct a Birth Certificate
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