Form 700-00207AP "Affidavit of Physician in Support of Petition for Issuance of New Birth Certificate" - Vermont

What Is Form 700-00207AP?

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

Form Details:

  • Released on December 1, 2015;
  • The latest edition provided by the Vermont Superior Court;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form 700-00207AP by clicking the link below or browse more documents and templates provided by the Vermont Superior Court.

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Download Form 700-00207AP "Affidavit of Physician in Support of Petition for Issuance of New Birth Certificate" - Vermont

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STATE OF VERMONT
SUPERIOR COURT
PROBATE DIVISION
Unit
Docket No.
In re:
Name on Certificate
AFFIDAVIT OF PHYSICIAN IN SUPPORT OF
PETITION FOR ISSUANCE OF NEW BIRTH CERTIFICATE
I state under oath:
1. I am a physician licensed to practice medicine in the State of ______________________.
2. My medical license number is __________________________________.
3. I have treated or evaluated the above named individual.
4. The above named individual has undergone surgical, hormonal, or other treatment appropriate for that
 Yes
 No
individual for the purpose of gender transition:
5. I make the following additional statements in support of the Petition:
Based on the foregoing, I support the issuance of a new birth certificate for the above named individual
 Male
 Female
showing the gender as
.
Date
Signature of Physician
Printed Name
Signed and sworn to before me:
Date
Signature of Notary Public
Expiration Date
700-00207AP – Affidavit of Physician in Support of Petition for Issuance of New Birth Certificate (12/2015)
Page 1 of 1
STATE OF VERMONT
SUPERIOR COURT
PROBATE DIVISION
Unit
Docket No.
In re:
Name on Certificate
AFFIDAVIT OF PHYSICIAN IN SUPPORT OF
PETITION FOR ISSUANCE OF NEW BIRTH CERTIFICATE
I state under oath:
1. I am a physician licensed to practice medicine in the State of ______________________.
2. My medical license number is __________________________________.
3. I have treated or evaluated the above named individual.
4. The above named individual has undergone surgical, hormonal, or other treatment appropriate for that
 Yes
 No
individual for the purpose of gender transition:
5. I make the following additional statements in support of the Petition:
Based on the foregoing, I support the issuance of a new birth certificate for the above named individual
 Male
 Female
showing the gender as
.
Date
Signature of Physician
Printed Name
Signed and sworn to before me:
Date
Signature of Notary Public
Expiration Date
700-00207AP – Affidavit of Physician in Support of Petition for Issuance of New Birth Certificate (12/2015)
Page 1 of 1