Form DH-430 "Affidavit of Amendment of Certificate of Live Birth" - Florida

What Is Form DH-430?

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

Form Details:

  • Released on May 1, 2004;
  • The latest edition provided by the Florida 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 DH-430 by clicking the link below or browse more documents and templates provided by the Florida Department of Health.

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Download Form DH-430 "Affidavit of Amendment of Certificate of Live Birth" - Florida

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.
INSTRUCTIONS – READ CAREFULLY
Any person who willfully and knowingly makes any false statement on a certificate, record, or report required by Chapter 382, Florida Statutes, or on an application for
an amendment thereof, commits a felony of the third degree, punishable as provided in s. 775.084, Florida Statutes.
1.
Complete only the upper half of the affidavit. This affidavit will be attached to the original birth certificate thus becoming part of the birth
record. Therefore, when completing, please use black typewriter ribbon or print clearly using black ink.
a.
REGISTRANT’S FULL NAME AT BIRTH – Enter the registrant’s (person for whom the record is filed) name as it SHOULD
APPEAR on the birth certificate.
b. STATE FILE NUMBER – Enter if known, otherwise, leave blank.
c. BIRTH DATE AND BIRTH PLACE – Enter correct date and place of birth of registrant.
d.
COLUMN 1 “ITEM OMITTED OR IN ERROR” – List the item(s) in error. Child’s Full Name, Mother’s Maiden Name, Father’s
Name, Date of Birth, etc.
e.
COLUMN 2 “BIRTH CERTIFICATE SHOWS” – Enter the information that is currently shown on the birth certificate.
f. COLUMN 3 “SHOULD BE” – Enter the correct information. There are enough lines to make four corrections. If more than four cor-
rections are indicated, you may enter two items per line thus allowing for eight corrections
2.
Affidavit must be signed by registrant if of legal age of 18 or if not of legal age by parent(s) or legal guardian in the presence of a notary
public. IF CORRECTION IS TO THE REGISTRANT’S NAME AND THE REGISTRANT IS UNDER THE AGE OF 18, THE
AFFIDAVIT MUST BE SIGNED BY BOTH MOTHER AND FATHER< BOTH SIGNATURES MUST BE NOTARIZED.
3.
AFFIDAVIT NOT ACCEPTABLE IF ERASURES OR ALTERATIONS ARE MADE.
IF ASSISTANCE IS NEEDED IN CONNECTION WITH THIS AMENDMENT, CONTACT THIS OFFICE AT (904) 359-6900, Ext. 9005.
AFFIDAVIT OF AMENDMENT OF CERTIFICATE OF LIVE BIRTH
(READ INSTRUCTIONS ABOVE BEFORE COMPLETING AND SIGNING)
REGISTRANT’S FULL NAME AT BIRTH
STATE FILE OR BIRTH NUMBER
109 -
DATE OF BIRTH
PLACE OF BIRTH/CITY OR TOWN
COUNTY
STATE
MONTH/DAY/YEAR
FLORIDA
ITEM OMITTED OR IN ERROR
BIRTH CERTIFICATE SHOWS
SHOULD BE
I HEREBY DECLARE UPON OATH THAT THE ABOVE STATEMENTS ARE TRUE AND CORRECT
Personally Known _ or Produced Identification _
SIGNATURE
Type Identification Produced _____________
___________________________________________________________________________
_____________________________________
COMMISSION EXPIRES: ________________
SUBSCRIBED AND SWORN BEFORE ME THIS
___________________________________
(Signature of Notary)
SEAL
____ day of _____________________, 20____
_____________________________________
(Printed Name of Notary)
I HEREBY DECLARE UPON OATH THAT THE ABOVE STATEMENTS ARE TRUE AND CORRECT
Personally Known _ or Produced Identification _
SIGNATURE
Type Identification Produced _______________
___________________________________________________________________________
______________________________________
COMMISSION EXPIRES: ________________
SUBSCRIBED AND SWORN BEFORE ME THIS
___________________________________
(Signature of Notary)
SEAL
____ day of ___________________, 20____
____________________________________
(Printed Name of Notary
DH Form 430, 5/04 (Replaces previous additions which may not be used) (Stock Number 5740-000-0430-8)
.
INSTRUCTIONS – READ CAREFULLY
Any person who willfully and knowingly makes any false statement on a certificate, record, or report required by Chapter 382, Florida Statutes, or on an application for
an amendment thereof, commits a felony of the third degree, punishable as provided in s. 775.084, Florida Statutes.
1.
Complete only the upper half of the affidavit. This affidavit will be attached to the original birth certificate thus becoming part of the birth
record. Therefore, when completing, please use black typewriter ribbon or print clearly using black ink.
a.
REGISTRANT’S FULL NAME AT BIRTH – Enter the registrant’s (person for whom the record is filed) name as it SHOULD
APPEAR on the birth certificate.
b. STATE FILE NUMBER – Enter if known, otherwise, leave blank.
c. BIRTH DATE AND BIRTH PLACE – Enter correct date and place of birth of registrant.
d.
COLUMN 1 “ITEM OMITTED OR IN ERROR” – List the item(s) in error. Child’s Full Name, Mother’s Maiden Name, Father’s
Name, Date of Birth, etc.
e.
COLUMN 2 “BIRTH CERTIFICATE SHOWS” – Enter the information that is currently shown on the birth certificate.
f. COLUMN 3 “SHOULD BE” – Enter the correct information. There are enough lines to make four corrections. If more than four cor-
rections are indicated, you may enter two items per line thus allowing for eight corrections
2.
Affidavit must be signed by registrant if of legal age of 18 or if not of legal age by parent(s) or legal guardian in the presence of a notary
public. IF CORRECTION IS TO THE REGISTRANT’S NAME AND THE REGISTRANT IS UNDER THE AGE OF 18, THE
AFFIDAVIT MUST BE SIGNED BY BOTH MOTHER AND FATHER< BOTH SIGNATURES MUST BE NOTARIZED.
3.
AFFIDAVIT NOT ACCEPTABLE IF ERASURES OR ALTERATIONS ARE MADE.
IF ASSISTANCE IS NEEDED IN CONNECTION WITH THIS AMENDMENT, CONTACT THIS OFFICE AT (904) 359-6900, Ext. 9005.
AFFIDAVIT OF AMENDMENT OF CERTIFICATE OF LIVE BIRTH
(READ INSTRUCTIONS ABOVE BEFORE COMPLETING AND SIGNING)
REGISTRANT’S FULL NAME AT BIRTH
STATE FILE OR BIRTH NUMBER
109 -
DATE OF BIRTH
PLACE OF BIRTH/CITY OR TOWN
COUNTY
STATE
MONTH/DAY/YEAR
FLORIDA
ITEM OMITTED OR IN ERROR
BIRTH CERTIFICATE SHOWS
SHOULD BE
I HEREBY DECLARE UPON OATH THAT THE ABOVE STATEMENTS ARE TRUE AND CORRECT
Personally Known _ or Produced Identification _
SIGNATURE
Type Identification Produced _____________
___________________________________________________________________________
_____________________________________
COMMISSION EXPIRES: ________________
SUBSCRIBED AND SWORN BEFORE ME THIS
___________________________________
(Signature of Notary)
SEAL
____ day of _____________________, 20____
_____________________________________
(Printed Name of Notary)
I HEREBY DECLARE UPON OATH THAT THE ABOVE STATEMENTS ARE TRUE AND CORRECT
Personally Known _ or Produced Identification _
SIGNATURE
Type Identification Produced _______________
___________________________________________________________________________
______________________________________
COMMISSION EXPIRES: ________________
SUBSCRIBED AND SWORN BEFORE ME THIS
___________________________________
(Signature of Notary)
SEAL
____ day of ___________________, 20____
____________________________________
(Printed Name of Notary
DH Form 430, 5/04 (Replaces previous additions which may not be used) (Stock Number 5740-000-0430-8)