Form VS24 "Affidavit to Amend a Record" - California

What Is Form VS24?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2020;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form VS24 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form VS24 "Affidavit to Amend a Record" - California

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AFFIDAVIT TO AMEND A RECORD
NO ERASURES, WHITEOUTS, PHOTOCOPIES,
_______________________________
______________________________
OR ALTERATIONS
STATE FILE NUMBER
LOCAL REGISTRATION NUMBER
BIRTH
DEATH
FETAL DEATH
TYPE OR PRINT CLEARLY IN BLACK INK ONLY – THIS AMENDMENT BECOMES AN ACTUAL PART OF THE OFFICIAL RECORD
PART I
INFORMATION TO LOCATE RECORD
1A. NAME—FIRST
1B. MIDDLE
1C. LAST
INFORMATION
2. SEX
3. DATE OF EVENT—MM/DD/CCYY
4. CITY OF EVENT
5. COUNTY OF EVENT
AS IT APPEARS
ON CURRENT
RECORD
6. FULL NAME OF PARENT AS STATED ON CURRENT RECORD
7. FULL NAME OF PARENT AS STATED ON CURRENT RECORD
PART II
STATEMENT OF CORRECTIONS TO BIRTH, DEATH, OR FETAL DEATH RECORD
8. ITEM
9. INCORRECT INFORMATION THAT APPEARS ON CURRENT RECORD
10. CORRECTED INFORMATION AS IT SHOULD APPEAR
NUMBER TO BE
CORRECTED
LIST ONE
ITEM PER
LINE
11.
REASON FOR
CORRECTION
We, the undersigned, hereby certify under penalty of perjury that we have personal knowledge of the above facts and
that the information given above is true and correct.
AFFIDAVITS
12A. SIGNATURE OF FIRST PERSON
12B. PRINTED NAME
12C. TITLE/RELATIONSHIP TO PERSON IN PART I
AND
SIGNATURES
12D. ADDRESS (STREET and NUMBER, CITY, STATE, ZIP)
12E. DATE SIGNED—MM/DD/CCYY
TWO
PERSONS
MUST SIGN
13A. SIGNATURE OF SECOND PERSON
13B. PRINTED NAME
13C. TITLE/RELATIONSHIP TO PERSON IN PART I
THIS FORM TO
CORRECT A
BIRTH, DEATH,
OR FETAL
13D. ADDRESS (STREET and NUMBER, CITY, STATE, ZIP)
13E. DATE SIGNED—MM/DD/CCYY
DEATH
RECORD
STATE/LOCAL
14. CDPH - VITAL RECORDS OR LOCAL REGISTRAR
15. DATE ACCEPTED FOR REGISTRATION
REGISTRAR
USE ONLY
FORM VS 24 (REV. 04/20)
STATE OF CALIFORNIA, DEPARTMENT OF PUBLIC HEALTH - VITAL RECORDS
AFFIDAVIT TO AMEND A RECORD
NO ERASURES, WHITEOUTS, PHOTOCOPIES,
_______________________________
______________________________
OR ALTERATIONS
STATE FILE NUMBER
LOCAL REGISTRATION NUMBER
BIRTH
DEATH
FETAL DEATH
TYPE OR PRINT CLEARLY IN BLACK INK ONLY – THIS AMENDMENT BECOMES AN ACTUAL PART OF THE OFFICIAL RECORD
PART I
INFORMATION TO LOCATE RECORD
1A. NAME—FIRST
1B. MIDDLE
1C. LAST
INFORMATION
2. SEX
3. DATE OF EVENT—MM/DD/CCYY
4. CITY OF EVENT
5. COUNTY OF EVENT
AS IT APPEARS
ON CURRENT
RECORD
6. FULL NAME OF PARENT AS STATED ON CURRENT RECORD
7. FULL NAME OF PARENT AS STATED ON CURRENT RECORD
PART II
STATEMENT OF CORRECTIONS TO BIRTH, DEATH, OR FETAL DEATH RECORD
8. ITEM
9. INCORRECT INFORMATION THAT APPEARS ON CURRENT RECORD
10. CORRECTED INFORMATION AS IT SHOULD APPEAR
NUMBER TO BE
CORRECTED
LIST ONE
ITEM PER
LINE
11.
REASON FOR
CORRECTION
We, the undersigned, hereby certify under penalty of perjury that we have personal knowledge of the above facts and
that the information given above is true and correct.
AFFIDAVITS
12A. SIGNATURE OF FIRST PERSON
12B. PRINTED NAME
12C. TITLE/RELATIONSHIP TO PERSON IN PART I
AND
SIGNATURES
12D. ADDRESS (STREET and NUMBER, CITY, STATE, ZIP)
12E. DATE SIGNED—MM/DD/CCYY
TWO
PERSONS
MUST SIGN
13A. SIGNATURE OF SECOND PERSON
13B. PRINTED NAME
13C. TITLE/RELATIONSHIP TO PERSON IN PART I
THIS FORM TO
CORRECT A
BIRTH, DEATH,
OR FETAL
13D. ADDRESS (STREET and NUMBER, CITY, STATE, ZIP)
13E. DATE SIGNED—MM/DD/CCYY
DEATH
RECORD
STATE/LOCAL
14. CDPH - VITAL RECORDS OR LOCAL REGISTRAR
15. DATE ACCEPTED FOR REGISTRATION
REGISTRAR
USE ONLY
FORM VS 24 (REV. 04/20)
STATE OF CALIFORNIA, DEPARTMENT OF PUBLIC HEALTH - VITAL RECORDS
valid.
APPLICATION TO AMEND A RECORD
TYPE OR PRINT CLEARLY IN BLACK INK ONLY
NO ERASURES, WHITEOUTS, PHOTOCOPIES, OR ALTERATIONS
If an acceptable application to amend the record is registered within one year of the date of the event, there is no processing fee; however, there
is a fee required for a certified copy.
Enclosed is the fee of $___________________________ for a certified copy of the newly amended record.
If an acceptable application to amend the record is registered one year or more after the date of the event, there is a fee for filing the affidavit,
which includes one certified copy. There is a fee for each additional certified copy. Please contact your Local Registrar, County Recorder, or the
State Registrar for the current fees, or visit our website at www.cdph.ca.gov.
Enclosed is the fee of $___________________________
for filing the affidavit and one certified copy of the newly amended record.
Enclosed is the fee of $
___________________________
for an additional certified copy(ies) of the newly amended record.
______________________________________________
______________________________________________________________________
Printed Name of Applicant
Mailing Address of Applicant
Telephone Number
(
) ________________________
______________________________________________________________________
City, State, ZIP Code
Email Address: _________________________________
GENERAL INFORMATION
1.
The original certificate cannot be altered.
2.
This amendment becomes a part of the original record, so please type or print clearly in black ink only.
3.
Please submit original amendment form only. Photocopies of the amendment form will be rejected.
4.
Your certified copy will include a copy of the original certificate with a copy of the amendment.
5.
The certified copy of the certificate and the attached amendment must remain together for the certified copy to be
READ INSTRUCTIONS CAREFULLY BEFORE COMPLETING THE FORM
1.
A Notarized Sworn Statement is required when requesting a certified authorized copy of the amended certificate.
For more information please visit our website at www.cdph.ca.gov.
2.
This form becomes a part of the original record – type or print clearly in black ink only.
3.
No erasures, whiteouts, photocopies, or alterations allowed.
4.
Complete Part I, Items 1 – 7, with the information as it appears on the current certificate.
5.
Enter the certificate item number(s) to be corrected, either from the original or subsequent amendment, in Part II—Item 8.
List one item per line.
6.
Enter the incorrect information that appears on the current certificate in the line(s) provided below Item 9.
7.
In Item 10, enter the correct information as it should appear for each item listed in Item 9.
8.
Enter the reason for the correction in Item 11.
9.
Read the affidavit statement. Two persons who are certifying to the statement of corrections must sign the form.
10. Do not write in Items 14 or 15. This space is reserved for State or Local Registrar use only.
11. Make check or money order payable to CDPH - Vital Records. When the paperwork is properly completed and signed by
two parties, return this form, together with the required fee(s), to:
California Department of Public Health
Vital Records - Amendments - MS 5105
P.O. Box 997410
Sacramento, CA 95899-7410
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