Form HD002109 "Application to Add a Father to a Birth Record" - Pennsylvania

What Is Form HD002109?

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

Form Details:

  • Released on March 1, 2019;
  • The latest edition provided by the Pennsylvania 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 fillable version of Form HD002109 by clicking the link below or browse more documents and templates provided by the Pennsylvania Department of Health.

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Download Form HD002109 "Application to Add a Father to a Birth Record" - Pennsylvania

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Application to Add a Father
INTERNAL USE ONLY
Date:
Initials:
to a Birth Record
HD002109 REV 3/19
Delivery:
P
PO
M
Status:
S
R
A
Type or print in ink
ERASURES, CROSS-OUTS OR ANY OTHER ALTERATIONS ARE UNACCEPTABLE.
For the reasons outlined in Part 4 below, this form is to be used to add a father to a child’s birth record that is registered in Pennsylvania. This form
may not be used to replace or remove a father previously named. Upon update to this record, an updated birth certificate will be issued.
PART 1: CONTACT INFORMATION
I am the parent of the child who is younger than 18 years of age.
I am the child listed on this record and am 18 years of age or older.
My current legal name:
(First)
(Middle)
(Last)
(Suffix)
Street:
Email address:
State:
Zip code:
Daytime phone:
City:
PART 2: BIRTH RECORD TO BE AMENDED
NAME AT BIRTH
DATE OF BIRTH
(First)
(Middle)
(Last)
(Suffix)
PLACE OF BIRTH
SEX
Male
Female
(County)
(City/borough/township)
(Hospital)
MOTHER’S NAME
(First)
(Middle)
(Last name prior to first marriage)
(Current last)
(Suffix)
PART 3: REQUESTED AMENDMENTS TO CHILD’S BIRTH RECORD
ADDITION OF FATHER’S NAME
(First)
(Middle)
(Last name prior to first marriage)
(Current last)
(Suffix)
FATHER’S DATE OF BIRTH
FATHER’S SOCIAL SECURITY NUMBER
FATHER’S PLACE OF BIRTH (STATE OR FOREIGN COUNTRY)
None
THIS CHILD’S NAME IS REQUESTED TO BE CHANGED TO THE FOLLOWING (OPTIONAL AND ONLY AVAILABLE TO CHILDREN UNDER 18 YEARS OF AGE):
(First)
(Middle)
(Last)
(Suffix)
PART 4: REASON AND DOCUMENTARY EVIDENCE (CHECK ONE REASON ONLY)
The birth mother and biological father were married at time of child’s birth, but the birth record did not reflect the marriage. An original,
government-issued marriage certificate is enclosed.
The birth mother and biological father married after the child’s birth. An original, government-issued marriage certificate is enclosed.
The unmarried birth mother and biological father have filed an
Acknowledgment of Paternity (AOP)
with the Pennsylvania Department of
Human Services (DHS). This AOP was sent to DHS on
. Call 1-800-932-0211.
Paternity of this child has been determined by a court of competent jurisdiction. The original court order with raised seal is enclosed.
PART 5: ACCEPTABLE FORMS OF IDENTIFICATION
I have included a legible photocopy of the following:
A valid driver’s license or other government-issued photo ID. If applying by mail, the address on my ID matches the mailing address listed in
Part 1. Expired IDs cannot be accepted.
I do not have a valid government-issued photo ID. Therefore, I have provided two current documents that verify my name and current
address (such as a utility bill, pay stub, bank statement, car registration or lease/rental agreement) as listed in Part 1.
See certificates.health.pa.gov for further information.
Application to Add a Father
INTERNAL USE ONLY
Date:
Initials:
to a Birth Record
HD002109 REV 3/19
Delivery:
P
PO
M
Status:
S
R
A
Type or print in ink
ERASURES, CROSS-OUTS OR ANY OTHER ALTERATIONS ARE UNACCEPTABLE.
For the reasons outlined in Part 4 below, this form is to be used to add a father to a child’s birth record that is registered in Pennsylvania. This form
may not be used to replace or remove a father previously named. Upon update to this record, an updated birth certificate will be issued.
PART 1: CONTACT INFORMATION
I am the parent of the child who is younger than 18 years of age.
I am the child listed on this record and am 18 years of age or older.
My current legal name:
(First)
(Middle)
(Last)
(Suffix)
Street:
Email address:
State:
Zip code:
Daytime phone:
City:
PART 2: BIRTH RECORD TO BE AMENDED
NAME AT BIRTH
DATE OF BIRTH
(First)
(Middle)
(Last)
(Suffix)
PLACE OF BIRTH
SEX
Male
Female
(County)
(City/borough/township)
(Hospital)
MOTHER’S NAME
(First)
(Middle)
(Last name prior to first marriage)
(Current last)
(Suffix)
PART 3: REQUESTED AMENDMENTS TO CHILD’S BIRTH RECORD
ADDITION OF FATHER’S NAME
(First)
(Middle)
(Last name prior to first marriage)
(Current last)
(Suffix)
FATHER’S DATE OF BIRTH
FATHER’S SOCIAL SECURITY NUMBER
FATHER’S PLACE OF BIRTH (STATE OR FOREIGN COUNTRY)
None
THIS CHILD’S NAME IS REQUESTED TO BE CHANGED TO THE FOLLOWING (OPTIONAL AND ONLY AVAILABLE TO CHILDREN UNDER 18 YEARS OF AGE):
(First)
(Middle)
(Last)
(Suffix)
PART 4: REASON AND DOCUMENTARY EVIDENCE (CHECK ONE REASON ONLY)
The birth mother and biological father were married at time of child’s birth, but the birth record did not reflect the marriage. An original,
government-issued marriage certificate is enclosed.
The birth mother and biological father married after the child’s birth. An original, government-issued marriage certificate is enclosed.
The unmarried birth mother and biological father have filed an
Acknowledgment of Paternity (AOP)
with the Pennsylvania Department of
Human Services (DHS). This AOP was sent to DHS on
. Call 1-800-932-0211.
Paternity of this child has been determined by a court of competent jurisdiction. The original court order with raised seal is enclosed.
PART 5: ACCEPTABLE FORMS OF IDENTIFICATION
I have included a legible photocopy of the following:
A valid driver’s license or other government-issued photo ID. If applying by mail, the address on my ID matches the mailing address listed in
Part 1. Expired IDs cannot be accepted.
I do not have a valid government-issued photo ID. Therefore, I have provided two current documents that verify my name and current
address (such as a utility bill, pay stub, bank statement, car registration or lease/rental agreement) as listed in Part 1.
See certificates.health.pa.gov for further information.
PART 6: FEE
Quantity Required
$20.00
Certificate cost:
Make check or money order payable to
Quantity:
X
“VITAL RECORDS.”
$ 0.00
Total:
Request for Waiver of Fee:
My child is under the age of 6 months and I have attached the incorrect birth certificate. Please send me the corrected certificate free
of charge.
Member of the U.S. armed forces - I am or my current legal spouse (includes widow/widower if not remarried) is in active service or was
honorably discharged from service.
Armed forces member’s name:
Service number:
Rank and branch of service:
PART 7: SIGNATURES AND NOTARIZED STATEMENT
To complete the application process, please sign this form. This form must be signed by both parents and the child (if over the age of 18 years).
However, if one parent has sole custody of the minor child, then only that parent is required to sign the form.
I have sole (exclusive physical and legal) custody of the minor child. I have attached a certified copy of the court order granting me
sole custody.
I am the only surviving parent of the minor child. The death certificate of the deceased parent is enclosed.
You must sign in front of a notary and have the form notarized if one of the following apply:
You are adding the biological father due to marriage to the child’s mother.
The child’s last name is changing and a court order has not been issued to effect this change.
The child’s first name or middle name is changing, and the child is more than 1 year of age (unless a court order has been issued to effect
this change).
By my signature below, I state I am the person whom I represent myself
Subscribed and sworn to or affirmed before me
to be herein, and I affirm the information within this form is complete
and accurate and made subject to the penalties of 18 Pa.C.S§4904
relating unsworn falsification to authorities. In addition, I acknowledge
that misstating my identity or assuming the identity of another person
(Signature of notary)
(Date)
may subject me to misdemeanor or felony criminal penalties for identity
theft pursuant to 18 Pa.C.S.§4120 or other sections of the Pennsylvania
Crimes Code.
(Signature of mother)
(Date)
SEAL
(Signature of father)
(Date)
MAIL THIS NOTARIZED REPORT AND SUPPORTING DOCUMENTATION TO:
Pa. Department of Health
Bureau of Health Statistics and Registries
ATTN: Birth Registry
(Signature of child required if over the age of 18)
(Date)
555 Walnut St., 6th Floor
Harrisburg, PA 17101-1934
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