Request for a New Birth Certificate - Montana

This Montana-specific printable "Request for a New Birth Certificate" is a part of the legal paperwork issued by the Montana Department of Public Health and Human Services.

Download the up-to-date PDF by clicking the link below and mail it as per the guidelines provided by the department.

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REQUEST FOR A NEW BIRTH CERTIFICATE
DPHHS – OFFICE OF VITAL RECORDS
PO BOX 4210
HELENA MT 59604
406-444-2685
Effective January 1, 1996, MCA 50-15-223 allows a new birth certificate to be created for a person born in Montana upon
the determination of paternity.
SUBMISSION OF THIS FORM MUST BE ACCOMPANIED BY EITHER:
1. A Certified Court Order determining paternity of the child.
2. A notarized acknowledgment of paternity signed by both parents.
AND THE APPROPRIATE FILING FEE.
Child's full name as listed on birth certificate:_____________________________________________________________
Child's Date of Birth: ____________________________ Child's Place of Birth: _________________________________
The new name of the child shall be:
(only last name can be changed)
__________________________________________________________________________________________________
First
Middle
Last
PLEASE GIVE CAREFUL CONSIDERATION TO THE NAME YOU WISH YOUR CHILD TO HAVE. THIS
IS A ONE-TIME OPPORTUNITY AND ANY FUTURE CHANGES TO THE SURNAME WILL REQUIRE A
COURT ORDER.
I certify that I am the natural mother and the above information is
I certify that I am the father and the above information is true.
.
true
_____________________________
_____________________________
Mother's Signature:
Father’s Signature:
Address: __________________________________________
Address: __________________________________________
City, State, Zip:_____________________________________
City, State, Zip:_____________________________________
Verification of Signer’s ID is Mandatory
Verification of Signer’s ID is Mandatory
State of: _________________________________________
State of: _________________________________________
County of:_______________________________________
County of:________________________________________
This document was signed and sworn to (or affirmed)
This document was signed and sworn to (or affirmed)
before me on :_________________________
before me on :_________________________
(Date)
(Date)
by______________________________________
by_________________________________________
(Name of Applicant)
(Name of Applicant)
__________________________________________
__________________________________________
(Notary’s Signature)
(Notary’s Signature)
[Official Stamp]
[Official Stamp]
REQUEST FOR A NEW BIRTH CERTIFICATE
DPHHS – OFFICE OF VITAL RECORDS
PO BOX 4210
HELENA MT 59604
406-444-2685
Effective January 1, 1996, MCA 50-15-223 allows a new birth certificate to be created for a person born in Montana upon
the determination of paternity.
SUBMISSION OF THIS FORM MUST BE ACCOMPANIED BY EITHER:
1. A Certified Court Order determining paternity of the child.
2. A notarized acknowledgment of paternity signed by both parents.
AND THE APPROPRIATE FILING FEE.
Child's full name as listed on birth certificate:_____________________________________________________________
Child's Date of Birth: ____________________________ Child's Place of Birth: _________________________________
The new name of the child shall be:
(only last name can be changed)
__________________________________________________________________________________________________
First
Middle
Last
PLEASE GIVE CAREFUL CONSIDERATION TO THE NAME YOU WISH YOUR CHILD TO HAVE. THIS
IS A ONE-TIME OPPORTUNITY AND ANY FUTURE CHANGES TO THE SURNAME WILL REQUIRE A
COURT ORDER.
I certify that I am the natural mother and the above information is
I certify that I am the father and the above information is true.
.
true
_____________________________
_____________________________
Mother's Signature:
Father’s Signature:
Address: __________________________________________
Address: __________________________________________
City, State, Zip:_____________________________________
City, State, Zip:_____________________________________
Verification of Signer’s ID is Mandatory
Verification of Signer’s ID is Mandatory
State of: _________________________________________
State of: _________________________________________
County of:_______________________________________
County of:________________________________________
This document was signed and sworn to (or affirmed)
This document was signed and sworn to (or affirmed)
before me on :_________________________
before me on :_________________________
(Date)
(Date)
by______________________________________
by_________________________________________
(Name of Applicant)
(Name of Applicant)
__________________________________________
__________________________________________
(Notary’s Signature)
(Notary’s Signature)
[Official Stamp]
[Official Stamp]

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