Form VSA411 "Statutory Declaration Re: Amendment of a Given Name on a Birth Record" - British Columbia, Canada

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STATUTORY DECLARATION
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RE: AMENDMENT OF A GIVEN NAME ON A BIRTH RECORD
Please read the instructions and documentation requirements on page 2 of this form.
APPLICANT’S INFORMATION
FOR OFFICE USE ONLY: AFS#
PRINT your name, address and identifying information clearly. This portion is used when mailing
your service or correspondence.
Surname
Given Name(s)
Mailing Address
City/Town/Village, Province/State, Country
Postal/ZIP Code
Home Phone (include area code)
Work Phone (include area code)
If Company, Attention:
DETAILS OF BIRTH AS CURRENTLY REGISTERED
Surname on Birth Record
Given Name(s) on Birth Record
Sex
Date of Birth
Place of Birth (City, Town or Village)
BRITISH
Month
Day
Year
COLUMBIA
Surname of Father/Parent
GIven Name(s)
Birthplace of Father/Parent (City, Prov/State, Country)
*
Maiden Surname
of Mother/Parent
Given Name(s)
Birthplace of Mother/Parent (City, Prov/State, Country)
*
Surname before marriage. The mother’s maiden surname is the last name she was given at birth, or if a legal change of name has been completed, her new last name as
noted on the Certificate of Change of Name.
AMENDMENT REQUESTED
r
Child is under 1 year old. The given name(s) for the above birth to be registered as:
Full Given Name(s)
r
Child is over 1 year old. Certified evidence of the usage of the proposed given name(s) obtained before the child’s 12
th
birthday is attached.
Full Given Name(s)
DECLARATION
I/We desire the amendment as shown above to be made pursuant to the Vital Statistics Act.
I/We have enclosed all certificates in my/our possession that relate to this event and understand that they will not be returned
on completion of this amendment.
I/We understand that all certificates issued prior to this amendment will be cancelled under section 40.1 of the Vital Statistics
Act.
I/We make this solemn declaration conscientiously believing it to be true, and knowing that it is of the same force and effect as if
made under oath.
}
}
}
X
Declared before me at
Signature of Mother/Parent/Guardian or Declarant
X
in the Province of British Columbia, this
day of
Day
Signature of Father/Parent/Guardian or Declarant
X
,
Month
Year
Signature of Lawyer, Articled Law Student, Notary Public,
or Commissioner for Taking Affidavits
Note: The signatures of BOTH parents/guardians are required for a change to the birth record of a minor.
This information is collected by the Vital Statistics Agency under section 26(c) of the Freedom of Information and Protection of Privacy Act, and will be used to fulfill the requirements of the Vital
Statistics Act for the release of change of name information. Should you have any questions about the collection of this personal information, please contact:
Manager, Vital Statistics Agency, 250 952-2681, PO Box 9657, Stn Prov Govt, Victoria BC V8W 9P3.
Fill out payment information on page 2 of this form.
VSA 411 2018/09/21
This form is fillable. Click in Surname field to begin.
STATUTORY DECLARATION
Clear form
Print
RE: AMENDMENT OF A GIVEN NAME ON A BIRTH RECORD
Please read the instructions and documentation requirements on page 2 of this form.
APPLICANT’S INFORMATION
FOR OFFICE USE ONLY: AFS#
PRINT your name, address and identifying information clearly. This portion is used when mailing
your service or correspondence.
Surname
Given Name(s)
Mailing Address
City/Town/Village, Province/State, Country
Postal/ZIP Code
Home Phone (include area code)
Work Phone (include area code)
If Company, Attention:
DETAILS OF BIRTH AS CURRENTLY REGISTERED
Surname on Birth Record
Given Name(s) on Birth Record
Sex
Date of Birth
Place of Birth (City, Town or Village)
BRITISH
Month
Day
Year
COLUMBIA
Surname of Father/Parent
GIven Name(s)
Birthplace of Father/Parent (City, Prov/State, Country)
*
Maiden Surname
of Mother/Parent
Given Name(s)
Birthplace of Mother/Parent (City, Prov/State, Country)
*
Surname before marriage. The mother’s maiden surname is the last name she was given at birth, or if a legal change of name has been completed, her new last name as
noted on the Certificate of Change of Name.
AMENDMENT REQUESTED
r
Child is under 1 year old. The given name(s) for the above birth to be registered as:
Full Given Name(s)
r
Child is over 1 year old. Certified evidence of the usage of the proposed given name(s) obtained before the child’s 12
th
birthday is attached.
Full Given Name(s)
DECLARATION
I/We desire the amendment as shown above to be made pursuant to the Vital Statistics Act.
I/We have enclosed all certificates in my/our possession that relate to this event and understand that they will not be returned
on completion of this amendment.
I/We understand that all certificates issued prior to this amendment will be cancelled under section 40.1 of the Vital Statistics
Act.
I/We make this solemn declaration conscientiously believing it to be true, and knowing that it is of the same force and effect as if
made under oath.
}
}
}
X
Declared before me at
Signature of Mother/Parent/Guardian or Declarant
X
in the Province of British Columbia, this
day of
Day
Signature of Father/Parent/Guardian or Declarant
X
,
Month
Year
Signature of Lawyer, Articled Law Student, Notary Public,
or Commissioner for Taking Affidavits
Note: The signatures of BOTH parents/guardians are required for a change to the birth record of a minor.
This information is collected by the Vital Statistics Agency under section 26(c) of the Freedom of Information and Protection of Privacy Act, and will be used to fulfill the requirements of the Vital
Statistics Act for the release of change of name information. Should you have any questions about the collection of this personal information, please contact:
Manager, Vital Statistics Agency, 250 952-2681, PO Box 9657, Stn Prov Govt, Victoria BC V8W 9P3.
Fill out payment information on page 2 of this form.
VSA 411 2018/09/21
AMENDMENT OF A GIVEN NAME
Section 10 of the Vital Statistics Act provides the authority to make an amendment to the given name(s) ONLY of a child where
the name(s) was/were changed or given to the child prior to their 12
birthday. This must be supported by documentary
th
evidence of the name(s) being used prior to the 12
birthday. All other circumstances require a legal change of name.
th
Who is eligible to apply for the amendment?
• If the child is 18 years of age or younger - the parents or guardians of the child.
• If the child is 19 years of age or older - the child is the only eligible applicant.
What to include with your application
Include the following items with your completed “Statutory Declaration Re: Amendment of a Given Name on a Birth Record”:
1. A minimum of two pieces of evidence to support the requested amendment under section 10 of the Vital Statistics Act:
}
}
• Baptismal record
In order to be considered valid evidence, documents must be BOTH:
• School records
• completed and dated prior to the person’s 12
birthday, AND
th
• Immunization cards
certified*
• Dental records
*A certified copy is a photocopy of a document, authenticated by an authorized official (lawyer,
• Health records
articled law student, notary public or commissioner for taking affidavits), as a true photocopy of the
• Aboriginal band records
original document.
2. Payment of the $27.00 fee for the amendment of a given name.
3. Payment for a new birth certificate if you would like one mailed or couriered to you once the amendment is complete.
($27.00 for a certificate delivered by mail; $60.00 for a certificate delivered by courier).
4. All birth certificates that list the child’s given name as it is prior to the amendment.
Birth certificates listing the pre-amendment name(s) are no longer valid once the name(s) is/are amended, so must be
returned to the Vital Statistics Agency.
Note: This request must be reviewed and may be denied if the supporting evidence provided is deemed insufficient.
CONTACT INFORMATION
Mailing Address:
Vital Statistics Agency, PO Box 9657 Stn Prov Govt, Victoria BC V8W 9P3
Telephone:
250 952-2681 (Victoria & Outside B.C.), 1 888 876-1633 (within B.C.)
Web:
www2.gov.bc.ca/gov/content/life-events
Apply for services in person at any Service BC Centre. Visit
www.servicebc.gov.bc.ca
for your nearest location.
FEES FOR NEW CERTIFICATES (ADD TO $27.00 FEE FOR CHANGE TO REGISTRATION)
Regular Service - $27.00 per certificate (Prints 2 - 5 business days
Courier Service - $60.00 per certificate (Prints the first business day
after the amendment is complete, and is mailed.)
after the amendment is complete, and is sent by courier.)
r
Birth Certificate (Individual Information only - 12.5 cm x 17.6 cm)
r
Birth Certificate (Individual Information only - 12.5 cm x 17.6 cm)
r
r
Birth Certificate (Includes Parental Information - 12.5 cm x 17.6 cm)
Birth Certificate (Includes Parental Information - 12.5 cm x 17.6 cm)
r
r
Registration Photocopy, Regular Service - $50.00 per photocopy
Registration Photocopy, Courier Service - $60.00 per photocopy
(average 20 business days processing time)
Vital Statistics sends certificate orders by mail unless courier service is requested. Delivery time is dependent on shipping destination. Courier delivery is not made to post office boxes,
apartment complexes, homes that use Super Box (community) mailboxes, or basement suites. Instead, Canada Post leaves a notice with instructions for you to pick up the certificate at
the closest postal facility. ID and signature are required upon pick up.
PAYMENT METHOD
q
q
q
q
q
Cheque
Money Order
Visa
MasterCard
American Express
+
+
+
Postdated cheques are not accepted. Make cheques or money orders payable to the Minister of Finance. Interac/Cash payments can be made in person at a Service BC
office. Visit
www.servicebc.gov.bc.ca
to find a location near you.
AMOUNT ENCLOSED:
X
$
27.00
Card holder signature
Amendment Fee
New Certificate(s)
PRINT card holder name as shown on credit card
$
(See fees above)
Expiry date
Credit Card #
27.00
Total Amount Enclosed
$
Note: Credit card information is not retained. Upon authorization of the payment request, all credit card information is destroyed.
VSA 411 2018/09/21
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