Form VS-166 Application for a New Birth Certificate Based on Parentage - Texas

Form vs-166 or the "Application For A New Birth Certificate Based On Parentage" is a form issued by the Texas Department of State Health Services.

Download a fillable PDF version of the Form vs-166 down below or find it on the Texas Department of State Health Services Forms website.

ADVERTISEMENT
APPLICATION FOR A NEW BIRTH CERTIFICATE BASED ON PARENTAGE
BUDGET ZZ 708-153
This form is used to ADD, REMOVE, or REPLACE information regarding the parents listed on the original birth
certificate according to an establishment of PARENTAGE or a COURT ORDER.
Child’s original birth information:
Type or Print in Blue/Black Ink
Texas
__________________________________________________
Date of Birth:____________/__________/____________ Place of Birth:____________________________________________,
Full name of child as registered at birth
month
day
year
city
Father’s name
Mother’s full maiden name
:________________________________________________________________
:________________________________________________________________________________
We/I hereby request a new birth certificate be filed as evidenced by:
ONE
PLEASE CHECK
OF THE FOLLOWING:
Attached certified copy of court decree (must send all pages of the court order) OR
A properly completed Acknowledgment of Paternity (form VS-159.1) (Date form was faxed to Vital Statistics Unit (VSU) or signed before a
certified entity: _________________) OR
Attached certified copy of the parents’ marriage license
A properly completed Rescission of Acknowledgment of Paternity (form VS-158) (Date Mailed to VSU _______________ )
INFORMATION TO BE PLACED ON NEW BIRTH CERTIFICATE:
:____________________________/_____________________/________________________________
FULL NEW NAME OF CHILD (may require a court order)
First
Middle
Last
Title To Appear On Birth Record:
Mother
Father
Parent; If Mother, Full Maiden Name
___________________/______________/_____________________
First
Middle
Last
Parent’s Name:
_____________________/______________/_____________________ Date of Birth:______/_____/________ Place of Birth:__________________________________
First
Middle
Last
month day
year
State or Foreign Country
Title To Appear On Birth Record:
Mother
Father
Parent; If Mother, Full Maiden Name
___________________/______________/_____________________
First
Middle
Last
Parent’s Name:
___________________/______________/_________________________ Date of Birth:______/_____/_______Place of Birth:__________________________________
First
Middle
Last
month day
year
State or Foreign Country
WARNING: The Penalty for knowingly making a false statement in this form can be 2-10 years in prison and a fine of up to $10,000. (Texas Health
and Safety Code, Chapter 195).
___________________________________________________________________________
_____________________________________________________________________________
Signature of PARENT or Legal Guardian swearing to this affidavit
Signature of PARENT or Legal Guardian swearing to this affidavit
______________________________________________________________________
________________________________________________________________________
Address
city
state
zip code
Address
city
state
zip code
(_____)_____________________________
(______)__________________________________
Daytime telephone number
Daytime telephone number
Sworn to and subscribed before me, this _________day of ______________________,
Sworn to and subscribed before me, this __________day of ______________________,
20_________.
20___________.
_____________________________________________________________________
_______________________________________________________________________
Signature of Notary Public, County Clerk, or other person
Signature of Notary Public, County Clerk, or other person
authorized to administer oaths
authorized to administer oaths
______________________________________________________________________________________
_________________________________________________________________________________________
Printed name and title
Printed name and title
SEE REVERSE SIDE FOR INSTRUCTIONS
The fee for filing a new birth certificate is $25.00 An additional fee of $22.00 must be included for a certified copy of the new birth certificate.
Mail this completed and NOTARIZED application with either the attached evidence (certified copy of court order/ marriage license), or filed an
Acknowledgment of Paternity, and the required fee to:
TEXAS VITAL STATISTICS
PO BOX 12040
AUSTIN TX 78711-2040
Page 1 of 3
APPLICATION FOR A NEW BIRTH CERTIFICATE BASED ON PARENTAGE
BUDGET ZZ 708-153
This form is used to ADD, REMOVE, or REPLACE information regarding the parents listed on the original birth
certificate according to an establishment of PARENTAGE or a COURT ORDER.
Child’s original birth information:
Type or Print in Blue/Black Ink
Texas
__________________________________________________
Date of Birth:____________/__________/____________ Place of Birth:____________________________________________,
Full name of child as registered at birth
month
day
year
city
Father’s name
Mother’s full maiden name
:________________________________________________________________
:________________________________________________________________________________
We/I hereby request a new birth certificate be filed as evidenced by:
ONE
PLEASE CHECK
OF THE FOLLOWING:
Attached certified copy of court decree (must send all pages of the court order) OR
A properly completed Acknowledgment of Paternity (form VS-159.1) (Date form was faxed to Vital Statistics Unit (VSU) or signed before a
certified entity: _________________) OR
Attached certified copy of the parents’ marriage license
A properly completed Rescission of Acknowledgment of Paternity (form VS-158) (Date Mailed to VSU _______________ )
INFORMATION TO BE PLACED ON NEW BIRTH CERTIFICATE:
:____________________________/_____________________/________________________________
FULL NEW NAME OF CHILD (may require a court order)
First
Middle
Last
Title To Appear On Birth Record:
Mother
Father
Parent; If Mother, Full Maiden Name
___________________/______________/_____________________
First
Middle
Last
Parent’s Name:
_____________________/______________/_____________________ Date of Birth:______/_____/________ Place of Birth:__________________________________
First
Middle
Last
month day
year
State or Foreign Country
Title To Appear On Birth Record:
Mother
Father
Parent; If Mother, Full Maiden Name
___________________/______________/_____________________
First
Middle
Last
Parent’s Name:
___________________/______________/_________________________ Date of Birth:______/_____/_______Place of Birth:__________________________________
First
Middle
Last
month day
year
State or Foreign Country
WARNING: The Penalty for knowingly making a false statement in this form can be 2-10 years in prison and a fine of up to $10,000. (Texas Health
and Safety Code, Chapter 195).
___________________________________________________________________________
_____________________________________________________________________________
Signature of PARENT or Legal Guardian swearing to this affidavit
Signature of PARENT or Legal Guardian swearing to this affidavit
______________________________________________________________________
________________________________________________________________________
Address
city
state
zip code
Address
city
state
zip code
(_____)_____________________________
(______)__________________________________
Daytime telephone number
Daytime telephone number
Sworn to and subscribed before me, this _________day of ______________________,
Sworn to and subscribed before me, this __________day of ______________________,
20_________.
20___________.
_____________________________________________________________________
_______________________________________________________________________
Signature of Notary Public, County Clerk, or other person
Signature of Notary Public, County Clerk, or other person
authorized to administer oaths
authorized to administer oaths
______________________________________________________________________________________
_________________________________________________________________________________________
Printed name and title
Printed name and title
SEE REVERSE SIDE FOR INSTRUCTIONS
The fee for filing a new birth certificate is $25.00 An additional fee of $22.00 must be included for a certified copy of the new birth certificate.
Mail this completed and NOTARIZED application with either the attached evidence (certified copy of court order/ marriage license), or filed an
Acknowledgment of Paternity, and the required fee to:
TEXAS VITAL STATISTICS
PO BOX 12040
AUSTIN TX 78711-2040
Page 1 of 3
VS-166 revised 09/2011
THIS FORM (with an attached court order or marriage license, or a filed Acknowledgment of Paternity in
the AOP Registry) MAY BE USED TO:
 Add a parent’s information to the birth certificate when the parent’s information is blank on the original birth
certificate. Evidence needed: a certified copy of a court order establishing the paternity of the child, OR a filed
Acknowledgment of Paternity in the AOP Registry if the biological parents are not married to each other, OR the
marriage license of the parents if they are now married to each other,
 Change the name and information of the parent listed on a child’s birth certificate to the biological father’s
name and information. This requires a certified copy of a court order OR an Acknowledgment of Paternity signed
by all three parties (the biological mother, the biological father, and the father presently listed on the birth
certificate) and filed in the Acknowledgment of Paternity Registry.
 Remove the father or mother’s information. This requires a certified copy of a court order. Please Note: A
Termination of Parental Rights will not remove a biological parent’s information from the birth certificate unless
the court order specifically states the biological parent’s name and information are to be removed.
 Substitute the Intended Parents’ names on the birth certificate based on a gestational agreement. This
requires a certified copy of a court order.
SPECIAL INSTRUCTIONS:
 If a marriage license or an Acknowledgment of Paternity is being used as evidence, BOTH parents must
sign the application before a notary public.
 If a certified copy of a court order is being used as evidence to change the birth certificate, only one parent
is required to sign the application before a notary public.
 If you are the father listed and you are having your name removed, a certified copy of a court order is
required to make any change to the child’s name. You are no longer a qualified applicant to receive a copy of the
child’s new birth certificate. Please submit only the $25.00 filing fee. You will receive notification when the
change is made.
 A legal guardian or the father listed on the birth certificate may sign the application before a notary public
if a certified copy of a court order establishing or removing paternity is presented as evidence with this
application.
 If one or both parents are deceased, a court order is required to file a new birth certificate to add the
biological father’s name and information.
 If a birth certificate has previously been changed based on paternity or a court order, a court order is
needed to file a new birth certificate with different information.
NO CHANGES WILL BE MADE TO A BIRTH CERTIFICATE WITHOUT THE FILING FEE
The fee to file a new birth certificate based on paternity, removal of a father or mother’s information,
or a gestational agreement is $25.00. The additional fee for a certified copy of the new birth record
is $22.00. If you have any questions, please call (888) 963-7111.
VS-166 revised 08/2015
Page 2 of 3
OFFICE USE ONLY
OFFICE USE ONLY
Remit No
By
ZZ 708-153
MAIL APPLICATION FOR
BIRTH AND DEATH RECORD
PLEASE PRINT. INCLUDE A PHOTOCOPY OF YOUR VALID ID WHEN SENDING IN THE REQUEST.
Make check or money orders payable to: DSHS - Vital Statistics. All funds are deposited directly to the Texas Comptroller of Public Accounts. For any
search of the files where a record is not found, the searching fee is not refundable or transferable.
Birth Certificates
Death Certificates
Cost X
# of
Total
Type
Type
Cost X
# of
copies=
copies=
Total
Standard Size
Long form
$22
Certified Copy (1 copy)
$20
Heirloom Flag
Bassinet
$60
Additional Copies
$3
Total (Check or money order payable to DSHS)
Total (Check or money order payable to DSHS)
I wish to make a voluntary contribution of $5.00 to promote healthy early childhood by supporting the Texas Home Visitation Program
administered by the Office of Early Childhood Coordination of Health and Human Services.
IDENTIFY BIRTH OR DEATH RECORD INFORMATION (Part I)
Last Name
First Name
Middle Name
Full Name of
Person on Record
Date of Birth/Death
Month
Day
Year
Sex
Place of
City or Town
County
State
Birth/Death
First Name
Middle Name
Maiden Name/Last Name
Full Name of
Parent 1
Maiden Name/Last Name
First Name
Middle Name
Full Name of
Parent 2
APPLICANT INFORMATION (Part II)
Applicant Name
Telephone #
Email Address
Full Mailing Address
Street Address
City
State
Zip
Purpose for obtaining this record:
Relationship to person listed above
I authorize mailing to the address below. I have verified that the address below will receive my order.
Name of Person Receiving Copies, if Different from Applicant
Mailing Address for Copies, if Different from Applicant
City
State
Zip
AFFIDAVIT OF PERSONAL KNOWLEDGE (MUST BE SIGNED IN PRESENCE OF A NOTARY PUBLIC) (Part III)
STATE OF
COUNTY OF
Before me on this day appeared _______________________________________
(Applicant name)
now residing at ____________________________________________________________________________________________________________
(Address)
(City)
(State)
who is related to the person named on Part I as ___________________________________and who on oath deposes and says that the contents of this
affidavit are true and correct.
(Relationship)
The applicant presented the following type and number of identification:
Applicant Signature______________________________________________
Sworn to and subscribed before me, this
day of
, 20
.
(Seal)
Signature of Notary Public and Notary ID Number___________________________________________
Typed or Printed Name: _______________________________________________________________
Commission Expires: ________________________________________________________________
Street Address:_____________________________________________________________________
City, State, Zip:_____________________________________________________________________
WARNING: IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT ON THIS FORM OR FOR SIGNING A
FORM WHICH CONTAINS A FALSE STATEMENT IS 2 TO 10 YEARS IMPRISONMENT AND A FINE OF UP TO $10,000. (HEALTH AND SAFETY CODE, CHAPTER 195, SEC. 195.003.
MAIL THIS APPLICATION, PAYMENT AND A VALID PHOTO ID TO:
Texas Vital Records Department of State Health Services
VS-142.3 Rev. 06212016
P.O. Box 12040 Austin, TX 78711-2040
Page 3 of 3

Download Form VS-166 Application for a New Birth Certificate Based on Parentage - Texas

1311 times
Rate
4.5(4.5 / 5) 65 votes
ADVERTISEMENT
Page of 3