APPLICATION TO CORRECT OR CHANGE A
MICHIGAN BIRTH RECORD
                           (FOR A CHILD NOW AGE ONE THROUGH FIVE YEARS)

MAIL APPLICATION WITH PAYMENT TO:
VITAL RECORDS CHANGES
P.O. Box 30721
Lansing, Michigan 48909

PLEASE READ AND FOLLOW INSTRUCTIONS
For additional information: (517) 335-8660, Mon-Fri 8:00 am - 5:00 pm ET

                                                    PLEASE PRINT CLEARLY AND LEGIBLY

PERSON REQUESTING A CORRECTION OR CHANGE TO A BIRTH RECORD Please provide your name and complete mailing address to mail the new record to you and a phone number to contact you if there are questions regarding this request.

Person Requesting Correction or Change:

________________________________________________________________________

Mailing Address:

________________________________________________________________________


City/State/Zip_____________________________________________________________

Daytime phone number to contact you: 

Area Code (            )__________________________________


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ELIGIBILITY
To be eligible to correct or change a child's birth record, you must be a parent named on the record, or a legal guardian or legal representative of the person(s) named on the record.   Legal guardians must include a copy of the court guardianship documents.   Legal representatives must provide information on official letterhead documenting that he/she represents either the person named on the record or an eligible parent or guardian.  Please check the item that applies to you:

[    ]   PARENT NAMED ON THE RECORD
[    ]   LEGAL GUARDIAN OF THE PERSON(S) NAMED ON THE RECORD
[    ]   LEGAL REPRESENTATIVE OF THE PERSON(S) NAMED ON THE RECORD

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REQUIRED DOCUMENTATION
You must include with this application, at least two (2) pieces of documentary evidence that are obtained from different sources. Exception: Documentation is NOT required for spelling errors of the child's first or middle name. Changes to certain information, such as names, date of birth and other key items, are subject to very specific supporting documentation. If you need more information or have specific questions, you may call our Changes Unit at (517) 335-8660. The types of supporting documents that are usually acceptable are listed below:

Hospital records
Statement from attendant at birth
Early medical records
Court documents
School records
Passport records
Insurance documents
Marriage records
Naturalization documents
Baptismal records
Immunization records

Please list below the documentary evidence you are submitting to make the change requested:

1.  ________________________________________________________________

2.  ________________________________________________________________

3.  ________________________________________________________________

Documentation will be returned to you when the request has been completed.

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INFORMATION TO LOCATE CHILD' S BIRTH RECORD


Child's Date of Birth: ____________________________________________________
                                             Month                          Day                  .       Year

Child's Name at Birth:

  _________________     _____________________   ________________________
             First                                      Middle                                           Last


Child's Gender:           [   ]   Male        [   ]  Female


Child's Place of Birth:

____________________________________________________________________________________
         Hospital (if known)                             City                                 County


Mother's Name Before First Married: 

__________________     ________________________      ____________________
         First                                                Middle                                              Last

Father's Name:

__________________      ________________________     ____________________
         First                                               Middle                                              Last


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A SIGNATURE IS REQUIRED TO PROCESS THE APPLICATION. 

WHEN A CHILD'S NAME IS BEING CHANGED DUE TO A MARRIAGE OF THE PARENTS NAMED ON THE RECORD, BOTH PARENTS' SIGNATURES ARE REQUIRED.

Signature of Person Requesting Change:

__________________________________________________    Date: __________

Other Signature: _____________________________________   Date: __________

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PAYMENT
The fee for correcting or changing  a Michigan birth record is $26.00 and includes one copy of the record with the changes made. Additional copies of the new record are available for $5.00 each when ordered at the same time. Payment must be made by check or money order and made payable to the "State of Michigan."

      
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PENALTIES:  Any person who willfully and knowingly makes false application to change or amend a Michigan
birth record may be fined not more than $1,000 and/or imprisoned not more than one (1) year.
MCL 333.2894(1)(b) and (c).
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FOR OFFICE USE ONLY - DO NOT WRITE IN THIS AREA

DCH-0860 Rev 06/2001 MCL 333.2871(1) and 333.2891(10)
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