Form VS21 "Application to Amend a Birth Record - Adjudication of Facts of Parentage" - California

Form VS21 or the "Application To Amend A Birth Record - Adjudication Of Facts Of Parentage" is a form issued by the California Department of Public Health.

Download a PDF version of the Form VS21 down below or find it on the California Department of Public Health Forms website.

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Download Form VS21 "Application to Amend a Birth Record - Adjudication of Facts of Parentage" - California

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APPLICATION TO AMEND A BIRTH RECORD — ADJUDICATION OF FACTS OF PARENTAGE
TYPE OR PRINT CLEARLY IN BLACK INK ONLY
NO ERASURES, WHITEOUTS, PHOTOCOPIES, OR ALTERATIONS
INSTRUCTIONS ON BACK
When a birth record is amended due to an adjudication of facts of parentage, the original record is sealed and a new birth record is
prepared.
A fee is required for the preparation of an amended birth record. This fee includes one certified copy of the newly prepared birth record.
There is a fee for each additional 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 preparation of the new birth record and one certified copy.
Enclosed is the fee of $ _________________________ for an additional certified copy(ies) of the newly prepared birth record.
____________________________________________
_______________________________________________________________
Printed Name of Applicant
Mailing Address of Applicant
_________________________
_______________________________________________________________
Telephone Number (
)
City, State, ZIP Code
ADJUDICATION OF FACTS OF PARENTAGE
NO ERASURES, WHITEOUTS, PHOTOCOPIES,
_____________________________
OR ALTERATIONS
STATE FILE NUMBER
TYPE OR PRINT CLEARLY IN BLACK INK ONLY
PART I
INFORMATION TO LOCATE RECORD
1A. NAME OF CHILD—FIRST
1B. MIDDLE
1C. LAST (BIRTH)
2. SEX
3. DATE OF BIRTH—MM/DD/CCYY
4. NAME OF PHYSICIAN, ATTENDANT OR CERTIFIER WHO ATTENDED THIS BIRTH
INFORMATION
AS IT APPEARS
ON ORIGINAL
5A. PLACE OF BIRTH—NAME OF HOSPITAL OR FACILITY
5B. CITY
5C. COUNTY
RECORD
6D.RELATIONSHIP
6A. FULL NAME OF PARENT—FIRST
6B. MIDDLE
6C. LAST (BIRTH)
MOTHER
FATHER
PARENT
7D.RELATIONSHIP
7A. FULL NAME OF PARENT—FIRST
7B. MIDDLE
7C. LAST (BIRTH)
MOTHER
FATHER
PARENT
PART II
INFORMATION AS IT IS TO APPEAR ON NEW RECORD
FULL NAME OF CHILD
8A. NAME OF CHILD—FIRST
8B. MIDDLE
8C. LAST
AS ORDERED BY
COURT
9D.RELATIONSHIP
9A. FULL NAME OF PARENT—FIRST
9B. MIDDLE
9C. LAST (BIRTH)
MOTHER
FATHER
PARENT
PARENT
10. STATE/FOREIGN COUNTRY OF BIRTH
11. DATE OF BIRTH—MM/DD/CCYY
12D
RELATIONSHIP
.
12A. FULL NAME OF PARENT—FIRST
12B. MIDDLE
12C. LAST (BIRTH)
MOTHER
FATHER
PARENT
PARENT
13. STATE/FOREIGN COUNTRY OF BIRTH
14. DATE OF BIRTH—MM/DD/CCYY
15. CDPH - VITAL RECORDS
16. DATE ACCEPTED FOR REGISTRATION
STATE
REGISTRAR
USE ONLY
STATE OF CALIFORNIA, DEPARTMENT OF PUBLIC HEALTH - VITAL RECORDS
FORM VS 21 (Rev. 1/16)
APPLICATION TO AMEND A BIRTH RECORD — ADJUDICATION OF FACTS OF PARENTAGE
TYPE OR PRINT CLEARLY IN BLACK INK ONLY
NO ERASURES, WHITEOUTS, PHOTOCOPIES, OR ALTERATIONS
INSTRUCTIONS ON BACK
When a birth record is amended due to an adjudication of facts of parentage, the original record is sealed and a new birth record is
prepared.
A fee is required for the preparation of an amended birth record. This fee includes one certified copy of the newly prepared birth record.
There is a fee for each additional 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 preparation of the new birth record and one certified copy.
Enclosed is the fee of $ _________________________ for an additional certified copy(ies) of the newly prepared birth record.
____________________________________________
_______________________________________________________________
Printed Name of Applicant
Mailing Address of Applicant
_________________________
_______________________________________________________________
Telephone Number (
)
City, State, ZIP Code
ADJUDICATION OF FACTS OF PARENTAGE
NO ERASURES, WHITEOUTS, PHOTOCOPIES,
_____________________________
OR ALTERATIONS
STATE FILE NUMBER
TYPE OR PRINT CLEARLY IN BLACK INK ONLY
PART I
INFORMATION TO LOCATE RECORD
1A. NAME OF CHILD—FIRST
1B. MIDDLE
1C. LAST (BIRTH)
2. SEX
3. DATE OF BIRTH—MM/DD/CCYY
4. NAME OF PHYSICIAN, ATTENDANT OR CERTIFIER WHO ATTENDED THIS BIRTH
INFORMATION
AS IT APPEARS
ON ORIGINAL
5A. PLACE OF BIRTH—NAME OF HOSPITAL OR FACILITY
5B. CITY
5C. COUNTY
RECORD
6D.RELATIONSHIP
6A. FULL NAME OF PARENT—FIRST
6B. MIDDLE
6C. LAST (BIRTH)
MOTHER
FATHER
PARENT
7D.RELATIONSHIP
7A. FULL NAME OF PARENT—FIRST
7B. MIDDLE
7C. LAST (BIRTH)
MOTHER
FATHER
PARENT
PART II
INFORMATION AS IT IS TO APPEAR ON NEW RECORD
FULL NAME OF CHILD
8A. NAME OF CHILD—FIRST
8B. MIDDLE
8C. LAST
AS ORDERED BY
COURT
9D.RELATIONSHIP
9A. FULL NAME OF PARENT—FIRST
9B. MIDDLE
9C. LAST (BIRTH)
MOTHER
FATHER
PARENT
PARENT
10. STATE/FOREIGN COUNTRY OF BIRTH
11. DATE OF BIRTH—MM/DD/CCYY
12D
RELATIONSHIP
.
12A. FULL NAME OF PARENT—FIRST
12B. MIDDLE
12C. LAST (BIRTH)
MOTHER
FATHER
PARENT
PARENT
13. STATE/FOREIGN COUNTRY OF BIRTH
14. DATE OF BIRTH—MM/DD/CCYY
15. CDPH - VITAL RECORDS
16. DATE ACCEPTED FOR REGISTRATION
STATE
REGISTRAR
USE ONLY
STATE OF CALIFORNIA, DEPARTMENT OF PUBLIC HEALTH - VITAL RECORDS
FORM VS 21 (Rev. 1/16)
The “Birth” name required on Vital Records (see Items 1C, 6C, 7C, 9C, and 12C) is the name given at
birth, or a name received through adoption, court-ordered name change, or naturalization. AKA’s (Also
Known As) and assumed names cannot be entered as the legal “Birth” name.
READ INSTRUCTIONS CAREFULLY BEFORE COMPLETING THE FORM
TYPE OR PRINT CLEARLY IN BLACK INK ONLY
NO ERASURES, WHITEOUTS, PHOTOCOPIES, OR ALTERATIONS
1. Type or print clearly in black ink only.
2. Enter the name of the child in Part 1, Items 1A – 1C, as shown on the original record.
3. Complete the information required to locate the record in Items 2 – 7D.
4. Enter the full name of the child as ordered by the court in Part II, Items 8A – 8C.
5. Complete the information required in Items 9A – 14.
6. Do not complete Items 15 and 16. This space is reserved for State Registrar use only.
7. For possible future transactions with the Social Security Administration or the Department of Motor Vehicles,
you should keep copies of all documents that you submit to our office. Once your child’s new birth certificate
is prepared, all supporting documents are sealed by our office and are not available to the public. A court
order is required to unseal the record.
8. Mail this form with the required fee(s) and a certified copy of the court order to:
California Department of Public Health - Vital Records
MS 5103
P.O. Box 997410
Sacramento, CA 95899-7410
Make check or money order payable to CDPH - Vital Records.
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