Form VS 23 Amendment of Birth Record to Reflect Court Order Change of Name - California

Form VS23 or the "Amendment Of Birth Record To Reflect Court Order Change Of Name" is a form issued by the California Department of Public Health.

The form was last revised in January 1, 2016 and is available for digital filing. Download an up-to-date Form VS23 in PDF-format down below or look it up on the California Department of Public Health Forms website.

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AMENDMENT OF BIRTH RECORD
TO REFLECT COURT ORDER CHANGE OF NAME
NO ERASURES, WHITEOUTS, PHOTOCOPIES,
____________________________________
OR ALTERATIONS
_______________________________________
STATE FILE NUMBER
LOCAL REGISTRATION NUMBER
TYPE OR PRINT CLEARLY IN BLACK INK ONLY – THIS AMENDMENT BECOMES A PART OF THE OFFICIAL BIRTH RECORD
PART I
INFORMATION TO LOCATE RECORD
1A. NAME—FIRST
1B. MIDDLE
1C. LAST (BIRTH)
2. SEX
3. DATE OF BIRTH—MM/DD/CCYY
4A. CITY OF BIRTH
4B. COUNTY OF BIRTH
INFORMATION
AS IT APPEARS
ON ORIGINAL
BIRTH RECORD
5D.RELATIONSHIP
5A. FULL NAME OF PARENT—FIRST
5B. MIDDLE
5C. LAST (BIRTH)
MOTHER
FATHER
PARENT
6D.RELATIONSHIP
6A. FULL NAME OF PARENT—FIRST
6B. MIDDLE
6C. LAST (BIRTH)
MOTHER
FATHER
PARENT
PART II
COURT ORDER INFORMATION
7. NAME OF COURT
8. COURT CASE NUMBER
GENERAL
INFORMATION
9. COUNTY
10. STATE
11. DATE OF COURT ORDER—MM/DD/CCYY
NEW NAME OF
12A. FIRST
12B. MIDDLE
12C. LAST
INDIVIDUAL AS
CHANGED BY
COURT ORDER
PART III
AFFIDAVIT AND SIGNATURE
I HEREBY CERTIFY UNDER PENALTY OF PERJURY THAT THE NAME OF THE INDIVIDUAL IDENTIFIED IN PART I WAS CHANGED
BY COURT ORDER AS STATED IN PART II.
13A. SIGNATURE OF APPLICANT
13B. PRINTED NAME
13C. DATE SIGNED—MM/DD/CCYY
USE BLACK INK
ONLY
13D. ADDRESS—STREET and NUMBER
13E. CITY
13F. STATE
13G. ZIP CODE
THIS IS TO CERTIFY THAT CDPH - VITAL RECORDS HAS REVIEWED A CERTIFIED COPY OF THE COURT ORDER DESCRIBED IN
STATE
PART II AND HAS ACCEPTED THIS AMENDMENT TO THE BIRTH RECORD AS PROVIDED BY STATUTE.
REGISTRAR
USE ONLY
14. CDPH - VITAL RECORDS
15. DATE ACCEPTED FOR REGISTRATION
STATE OF CALIFORNIA, DEPARTMENT OF PUBLIC HEALTH - VITAL RECORDS
FORM VS 23 (Rev. 1/16)
AMENDMENT OF BIRTH RECORD
TO REFLECT COURT ORDER CHANGE OF NAME
NO ERASURES, WHITEOUTS, PHOTOCOPIES,
____________________________________
OR ALTERATIONS
_______________________________________
STATE FILE NUMBER
LOCAL REGISTRATION NUMBER
TYPE OR PRINT CLEARLY IN BLACK INK ONLY – THIS AMENDMENT BECOMES A PART OF THE OFFICIAL BIRTH RECORD
PART I
INFORMATION TO LOCATE RECORD
1A. NAME—FIRST
1B. MIDDLE
1C. LAST (BIRTH)
2. SEX
3. DATE OF BIRTH—MM/DD/CCYY
4A. CITY OF BIRTH
4B. COUNTY OF BIRTH
INFORMATION
AS IT APPEARS
ON ORIGINAL
BIRTH RECORD
5D.RELATIONSHIP
5A. FULL NAME OF PARENT—FIRST
5B. MIDDLE
5C. LAST (BIRTH)
MOTHER
FATHER
PARENT
6D.RELATIONSHIP
6A. FULL NAME OF PARENT—FIRST
6B. MIDDLE
6C. LAST (BIRTH)
MOTHER
FATHER
PARENT
PART II
COURT ORDER INFORMATION
7. NAME OF COURT
8. COURT CASE NUMBER
GENERAL
INFORMATION
9. COUNTY
10. STATE
11. DATE OF COURT ORDER—MM/DD/CCYY
NEW NAME OF
12A. FIRST
12B. MIDDLE
12C. LAST
INDIVIDUAL AS
CHANGED BY
COURT ORDER
PART III
AFFIDAVIT AND SIGNATURE
I HEREBY CERTIFY UNDER PENALTY OF PERJURY THAT THE NAME OF THE INDIVIDUAL IDENTIFIED IN PART I WAS CHANGED
BY COURT ORDER AS STATED IN PART II.
13A. SIGNATURE OF APPLICANT
13B. PRINTED NAME
13C. DATE SIGNED—MM/DD/CCYY
USE BLACK INK
ONLY
13D. ADDRESS—STREET and NUMBER
13E. CITY
13F. STATE
13G. ZIP CODE
THIS IS TO CERTIFY THAT CDPH - VITAL RECORDS HAS REVIEWED A CERTIFIED COPY OF THE COURT ORDER DESCRIBED IN
STATE
PART II AND HAS ACCEPTED THIS AMENDMENT TO THE BIRTH RECORD AS PROVIDED BY STATUTE.
REGISTRAR
USE ONLY
14. CDPH - VITAL RECORDS
15. DATE ACCEPTED FOR REGISTRATION
STATE OF CALIFORNIA, DEPARTMENT OF PUBLIC HEALTH - VITAL RECORDS
FORM VS 23 (Rev. 1/16)
APPLICATION TO AMEND A BIRTH RECORD TO REFLECT COURT ORDER CHANGE OF NAME
TYPE OR PRINT CLEARLY IN BLACK INK ONLY
NO ERASURES, WHITEOUTS, PHOTOCOPIES, OR ALTERATIONS
I hereby make application to amend the birth certificate for the individual identified. A fee is required to file the amendment, but the fee
includes one certified copy of the newly amended 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 filing the amendment and one certified copy of the newly amended record.
Enclosed is the fee of $ ________________________ for an additional certified copy(ies) of the newly amended birth record.
___________________________________________
_________________________________________________________________
Printed Name of Applicant
Mailing Address of Applicant
________________________
_________________________________________________________________
Telephone Number (
)
City, State, ZIP Code
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 valid.
READ INSTRUCTIONS CAREFULLY BEFORE COMPLETING THE FORM
1. This form becomes a part of the original record – type or print clearly in black ink only.
2. No erasures, whiteouts, photocopies, or alterations allowed.
3. Complete Part I, Items 1A – 6D, with the information as it appears on the original certificate.
4. Complete Part II, Items 7 – 11, with the court order information.
5. Enter the new name(s) in Items 12A – 12C EXACTLY as stated in the court order.
6. The applicant must sign in Item 13A, print his/her name in Item 13B, enter the date signed in Item 13C, and
complete the address information in Items 13D – 13G.
7. Do not complete items 14 or 15. This space is reserved for State Registrar use only.
8. Make check or money order payable to CDPH - Vital Records. When all paperwork is properly completed and
signed, mail the form, 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

Download Form VS 23 Amendment of Birth Record to Reflect Court Order Change of Name - California

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