Form REG-L2 "Request Form and Attestation to Amend Sex Designation to Reflect Gender Identity on a Birth Certificate - Adult" - New Jersey

What Is Form REG-L2?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2019;
  • The latest edition provided by the New Jersey Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form REG-L2 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form REG-L2 "Request Form and Attestation to Amend Sex Designation to Reflect Gender Identity on a Birth Certificate - Adult" - New Jersey

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State of New Jersey Department of Health
Office of Vital Statistics and Registry
Request Form and Attestation (REG-L2)
to Amend Sex Designation
to Reflect Gender Identity on a Birth Certificate - Adult
In compliance with N.J.S.A. 26:8-40.12, the State Registrar shall issue an amended certificate of birth to a person born in the State of New
Jersey who requests an amended certificate of birth which shows the gender and, if applicable, the new name of the person if it has been
changed. Specifically, “The State Registrar shall issue the amended certificate of birth upon receipt of: (1) a certified copy of an
order from a court of competent jurisdiction which indicates that the name of the person has been changed, if the person has
changed his or her name; and (2) a form provided by the State Registrar and completed by the person, […]which affirms the
following language: ‘I, (petitioner’s current full name), hereby attest under penalty of perjury that the request for a change in
gender to (female, male, or undesignated/non-binary) is to conform my legal gender to my gender identity and is not for any
fraudulent purpose.’”
QUESTION 1. PETITIONER’S INFORMATION
1A. Petitioner’s Name
(as it appears on your current Birth Certificate)
First
Middle
Last
1B. Petitioner’s Current Legal Name
*Required attachment: Proof of identity showing your full legal name.
First
Middle
Last
1C. Is your current legal name different from that which appears on your current Birth Certificate?
Yes
No
*If yes, required attachment: A certified copy of the legal name change court order, or Marriage Certificate.
1D. Date of Birth
1E. Place of Birth
(MM/DD/YYYY)
City
County
1F. Mother/Parent A Name
(as it appears on your current Birth Certificate)
First
Middle
Last
1G. Father/Parent B Name
(as it appears on your current Birth Certificate)
First
Middle
Last
1H. Petitioner’s Mailing Address
Street Address
City
State
Zip Code
Country
1I. Petitioner’s Phone Number
1J. Petitioner’s Email Address
(
)
QUESTION 2. INFORMATION REQUIRED FOR AMENDMENT OF YOUR BIRTH CERTIFICATE
2A. Which sex designation is currently shown on your Birth Certificate?
Female
Male
Not Yet Determined
2B. Which sex designation/gender identity are you requesting to be shown on your amended Birth Certificate?
Female
Male
Undesignated/Non-binary
“Undesignated/Non-binary” encompasses all gender identities that are not exclusively male or female.
2C. Are you requesting a name change on the amended Birth Certificate?
Yes ($2 fee)
No -
If no, skip to Question 3.
2D. If requesting a name change, have you obtained a court order for a name change?
Yes
No -
If no, name change will not be processed. Skip to Question 3.
*If yes, required attachment: A certified copy of the legal name change court order.
2E. If requesting a name change with court order, what is the current full legal name indicated on the court order?
This is the full legal name that will appear on the amended Birth Certificate.
First
Middle
Last
REG-L2 | Feb 19
Page 1 / 2
State of New Jersey Department of Health
Office of Vital Statistics and Registry
Request Form and Attestation (REG-L2)
to Amend Sex Designation
to Reflect Gender Identity on a Birth Certificate - Adult
In compliance with N.J.S.A. 26:8-40.12, the State Registrar shall issue an amended certificate of birth to a person born in the State of New
Jersey who requests an amended certificate of birth which shows the gender and, if applicable, the new name of the person if it has been
changed. Specifically, “The State Registrar shall issue the amended certificate of birth upon receipt of: (1) a certified copy of an
order from a court of competent jurisdiction which indicates that the name of the person has been changed, if the person has
changed his or her name; and (2) a form provided by the State Registrar and completed by the person, […]which affirms the
following language: ‘I, (petitioner’s current full name), hereby attest under penalty of perjury that the request for a change in
gender to (female, male, or undesignated/non-binary) is to conform my legal gender to my gender identity and is not for any
fraudulent purpose.’”
QUESTION 1. PETITIONER’S INFORMATION
1A. Petitioner’s Name
(as it appears on your current Birth Certificate)
First
Middle
Last
1B. Petitioner’s Current Legal Name
*Required attachment: Proof of identity showing your full legal name.
First
Middle
Last
1C. Is your current legal name different from that which appears on your current Birth Certificate?
Yes
No
*If yes, required attachment: A certified copy of the legal name change court order, or Marriage Certificate.
1D. Date of Birth
1E. Place of Birth
(MM/DD/YYYY)
City
County
1F. Mother/Parent A Name
(as it appears on your current Birth Certificate)
First
Middle
Last
1G. Father/Parent B Name
(as it appears on your current Birth Certificate)
First
Middle
Last
1H. Petitioner’s Mailing Address
Street Address
City
State
Zip Code
Country
1I. Petitioner’s Phone Number
1J. Petitioner’s Email Address
(
)
QUESTION 2. INFORMATION REQUIRED FOR AMENDMENT OF YOUR BIRTH CERTIFICATE
2A. Which sex designation is currently shown on your Birth Certificate?
Female
Male
Not Yet Determined
2B. Which sex designation/gender identity are you requesting to be shown on your amended Birth Certificate?
Female
Male
Undesignated/Non-binary
“Undesignated/Non-binary” encompasses all gender identities that are not exclusively male or female.
2C. Are you requesting a name change on the amended Birth Certificate?
Yes ($2 fee)
No -
If no, skip to Question 3.
2D. If requesting a name change, have you obtained a court order for a name change?
Yes
No -
If no, name change will not be processed. Skip to Question 3.
*If yes, required attachment: A certified copy of the legal name change court order.
2E. If requesting a name change with court order, what is the current full legal name indicated on the court order?
This is the full legal name that will appear on the amended Birth Certificate.
First
Middle
Last
REG-L2 | Feb 19
Page 1 / 2
State of New Jersey Department of Health
Office of Vital Statistics and Registry
Request Form and Attestation (REG-L2)
to Amend Sex Designation
to Reflect Gender Identity on a Birth Certificate - Adult
QUESTION 3. ORDER CERTIFIED COPIES OF AMENDED BIRTH CERTIFICATE
3A. Do you want certified copies of the amended Birth Certificate at this time?
Yes - 3B. How many copies? ______________
($6 for first copy; $2 for each additional copy ordered at the same time as the first request.) See fees section below.
No
ATTESTATION
Attestation and signature are required to process request.
I, _____________________________________________
, hereby attest under penalty
(petitioner’s current full name)
of perjury that my request for a change in gender to
Female
Male
Undesignated/Non-binary is to
conform my legal gender to my gender identity and is not for any fraudulent purpose.
Petitioner’s Signature _____________________________________________
Date _________________
FEES, IF APPLICABLE
.
Please calculate fees owed below. Make check or money order payable to “Treasurer, State of New Jersey.” Do not send cash
______ $6.00 one-time fee for the first requested certified copy of the amended birth certificate.
______ $2.00 X _____ (for each additional certified copy of the amended birth certificate ordered at the same time as
the first request).
______ $2.00 one-time fee to register a court ordered legal name change with the State of New Jersey, Department of
Health, Office of Vital Statistics and Registry. Only submit this fee if requesting a name change on the amended
Birth Certificate (and submitting court order for name change with this request).
.
______ $TOTAL Submitted
Make check or money order payable to “Treasurer, State of New Jersey.” Do not send cash
Note: For copies of certified birth certificates requested at any later date, the fee is $25.00 for the first copy and $2.00
for each additional copy.
SUBMISSION BY MAIL WITH REQUIRED ATTACHMENTS AND FEES, IF APPLICABLE
Office of Vital Statistics & Registry – Records Modification Unit
NJ Department of Health
P.O. Box 370
Trenton, NJ 08625-0370
Amendment requests are not accepted in-person.
Questions? Please see related “Frequently Asked Questions” available on the NJ Department of Health - Office
of Vital Statistics and Registry website.
REG-L2 | Feb 19
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