Form VS 24 Affidavit to Amend a Birth/Death Record - California

Form VS24 is a California Department of Public Health form also known as the "Affidavit To Amend A Birth/death Record". The latest edition of the form was released in January 1, 2016 and is available for digital filing.

Download a PDF version of the Form VS24 down below or find it on California Department of Public Health Forms website.

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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 ORIGINAL
RECORD
6. FULL NAME OF PARENT AS STATED ON ORIGINAL RECORD
7. FULL NAME OF PARENT AS STATED ON ORIGINAL RECORD
PART II
STATEMENT OF CORRECTIONS TO BIRTH, DEATH, OR FETAL DEATH RECORD
8. ITEM
9. INCORRECT INFORMATION THAT APPEARS ON ORIGINAL 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
STATE OF CALIFORNIA, DEPARTMENT OF PUBLIC HEALTH - VITAL RECORDS
FORM VS 24 (REV. 1/16)
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 ORIGINAL
RECORD
6. FULL NAME OF PARENT AS STATED ON ORIGINAL RECORD
7. FULL NAME OF PARENT AS STATED ON ORIGINAL RECORD
PART II
STATEMENT OF CORRECTIONS TO BIRTH, DEATH, OR FETAL DEATH RECORD
8. ITEM
9. INCORRECT INFORMATION THAT APPEARS ON ORIGINAL 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
STATE OF CALIFORNIA, DEPARTMENT OF PUBLIC HEALTH - VITAL RECORDS
FORM VS 24 (REV. 1/16)
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
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
This form becomes a part of the original record – type or print clearly in black ink only.
1.
2.
No erasures, whiteouts, photocopies, or alterations allowed.
3.
Enter the Local Registration Number in the space provided in the upper right-hand corner of the form.
Complete Part I, Items 1 – 7, with the information as it appears on the original certificate.
4.
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 original 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
MS 5103
P.O. Box 997410
Sacramento, CA 95899-7410

Download Form VS 24 Affidavit to Amend a Birth/Death Record - California

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