Form DOH422-143 "Request to Change Sex Designation on a Birth Certificate for an Adult" - Washington

This version of the form is not currently in use and is provided for reference only.
Download this version of Form DOH422-143 for the current year.

What Is Form DOH422-143?

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

Form Details:

  • Released on October 1, 2019;
  • The latest edition provided by the Washington State 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 DOH422-143 by clicking the link below or browse more documents and templates provided by the Washington State Department of Health.

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Download Form DOH422-143 "Request to Change Sex Designation on a Birth Certificate for an Adult" - Washington

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Request to Change Sex Designation
on a Birth Certificate for an Adult
DOH 422-143 October 2019
Who may request a change?
An adult who was born in Washington State and wants to change their sex designation on their birth certificate
may request the change using this form.
What is required under WAC 246-490-075?
Adults (over 18 years of age or an emancipated minor)
The request form must be completed by a person requesting to change the sex designation on their birth
certificate. Emancipated minors must include proof of legal emancipation under chapter 13.64 RCW (i.e.
certified court order). Guardians acting on behalf of an adult must include proof of guardianship appointed
under chapter 11.92 RCW.
The request form must be signed in the presence of a Notary Public.
Applicable Fees
There is no fee to amend the record. If you want a certified copy of the new birth certificate, complete a
Certificate
Order Form
and include $20 for each certified copy requested. Make check or money order payable to DOH.
Additional Information
If your full current legal name is different than the full name listed on your birth certificate, you must provide a
certified legal name change court order with this request form. If you want your full current legal name amended
on your birth certificate, indicate by checking the appropriate box. Additional proof documentation might be
requested. For information on legally changing your name, please visit our website at https://www.doh.wa.gov.
Use by government agencies
At this time we are unsure if other agencies, such as Passport, will accept these amended certificates. For those
that include change of sex, nothing on the record will indicate a change was made. This will make it difficult to
connect the current record with the previous name on other documentation. In some cases, a court order might
be needed for full use of the new name and sex designation.
Submitting the form in person:
101 Israel Rd. SE
Tumwater, WA 98501
8:30 a.m. – 4:00 p.m.
Mailing the form:
Center for Health Statistics
Department of Health
PO Box 47814
Olympia WA 98504
Phone: 360-236-4300
Email:
SexDesignationChange@doh.wa.gov
Web:
https://www.doh.wa.gov
Request to Change Sex Designation
on a Birth Certificate for an Adult
DOH 422-143 October 2019
Who may request a change?
An adult who was born in Washington State and wants to change their sex designation on their birth certificate
may request the change using this form.
What is required under WAC 246-490-075?
Adults (over 18 years of age or an emancipated minor)
The request form must be completed by a person requesting to change the sex designation on their birth
certificate. Emancipated minors must include proof of legal emancipation under chapter 13.64 RCW (i.e.
certified court order). Guardians acting on behalf of an adult must include proof of guardianship appointed
under chapter 11.92 RCW.
The request form must be signed in the presence of a Notary Public.
Applicable Fees
There is no fee to amend the record. If you want a certified copy of the new birth certificate, complete a
Certificate
Order Form
and include $20 for each certified copy requested. Make check or money order payable to DOH.
Additional Information
If your full current legal name is different than the full name listed on your birth certificate, you must provide a
certified legal name change court order with this request form. If you want your full current legal name amended
on your birth certificate, indicate by checking the appropriate box. Additional proof documentation might be
requested. For information on legally changing your name, please visit our website at https://www.doh.wa.gov.
Use by government agencies
At this time we are unsure if other agencies, such as Passport, will accept these amended certificates. For those
that include change of sex, nothing on the record will indicate a change was made. This will make it difficult to
connect the current record with the previous name on other documentation. In some cases, a court order might
be needed for full use of the new name and sex designation.
Submitting the form in person:
101 Israel Rd. SE
Tumwater, WA 98501
8:30 a.m. – 4:00 p.m.
Mailing the form:
Center for Health Statistics
Department of Health
PO Box 47814
Olympia WA 98504
Phone: 360-236-4300
Email:
SexDesignationChange@doh.wa.gov
Web:
https://www.doh.wa.gov
Request to Change Sex Designation
on a Birth Certificate for an Adult
DOH 422-143 October 2019
CLEARLY PRINT OR TYPE INFORMATION. This request form must be signed in the presence of a Notary Public. See the
front page Information Sheet for instructions and further details. WARNING: Willfully providing a false statement to the
Department of Health for a certificate is a gross misdemeanor under Washington law. RCW 70.58.280(2).
Complete in Ink
Office Use Only
Certificate Number
Fee Number
Date Amended
Staff Initials
Amendment Number
Applicant’s Information
First name
Middle name
Last name
(as appears on Birth Certificate)
(as appears on Birth Certificate)
(as appears on Birth Certificate)
Full current legal name
(if different, submit certified legal name change court order)
First
Middle
Last
Amend name on birth certificate?
Date of Birth
Place of Birth
(MM/DD/YYYY)
(City or County)
Yes
No
Mother/ Parent 1 Birth Name
(First, Middle, Last)
Father/ Parent 2 Birth Name, if applicable
(First, Middle, Last)
Mailing Address
(Address, City, State, ZIP code, Country)
Phone number
Email Address
(
)
-
What sex designation is currently shown on your birth certificate?..............................
Male
Female
X
What sex designation are you requesting to show on your birth certificate?................
Male
Female
X
By signing and submitting this document to the Department of Health, you certify under penalty of perjury under the laws of
the State of Washington (chapter 9A.72 RCW) that the foregoing is true and correct.
Requestor signature_______________________________________________
Signed and sworn before me on ______________ by____________________
Date (MM/DD/YY)
Print Full Name of Requestor
Place notary
State of ________________________, County of _______________________
seal here
____________________________________, __________________________
Signature of Witness or Notarial Officer
Title of Office
____________________________ My commission expires _______________
Printed Full Name of Witness or Notarial Officer
Notary Use Only
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