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 FATHER'S NAME BE ADDED
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 Father's Name Be Added:
___________________________________________________________________
Mailing Address: _____________________________________________________
City/State/Zip________________________________________________________
Daytime phone number to contact you:
Area Code (
)
___________________________________________________
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ELIGIBILITY
To be eligible to add a father to a birth record, you
must be the person named on the record and at least 18 years old, a parent named or to be
named on the record, or a legal guardian or legal representative of the person(s) named or
to be 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. Please check the item that applies to you:
[ ] PERSON NAMED ON RECORD (must be at least 18
years old)
[ ] PARENT NAMED ON RECORD OR TO BE NAMED ON THE RECORD
[ ] LEGAL GUARDIAN OF THE PERSON(S) NAMED OR TO BE NAMED ON
THE RECORD
[ ] LEGAL REPRESENTATIVE OF THE PERSON(S) NAMED OR TO BE
NAMED ON THE
RECORD
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REQUIRED DOCUMENTATION
The information on the father may be
added to the birth record based upon a certified court determination of paternity, an
Order of Filiation, a properly filed Affidavit of Parentage or Acknowledgment of
Paternity.
Effective June 1, 1997, all paternity acknowledgments
were filed with the Michigan Department of Community Health. If an Affidavit of Parentage,
Order of Filiation or court order was filed with this office after June 1, 1997, and
registered correctly with the Central Paternity Registry, you need not furnish a copy of
that document. Prior to June 1, 1997, it is the applicant's responsibility to submit a
true or certified copy of the Affidavit of Parentage, Order of Filiation or court order
filed in the probate court, with the application to name a father.
If an Affidavit of Parentage has never been filed for this child,
contact the Changes Unit at (517) 335-8660 to request one be mailed
to you.
Please check the appropriate box below for documentation submitted.
[ ] Father is not registered with the Central Paternity Registry. An original signed and notarized Affidavit of Parentage is attached. [ ] A court order is attached. (Court order will be returned to you) [ ] Affidavit of Parentage has already been duly signed and notarized, and has been submitted to the Central Paternity Registry. *********************************************************************** INDICATE FATHER'S FULL NAME AND INFORMATION TO BE ADDED Father's Full Name: ________________ ___________________ ________________________ First Middle Last Father's Place of Birth: _____________________________________________ State or Country (if not U.S.) Father's Date of Birth: _____________________________________________ Month Day Year Father's Social Security Number * : ____________________________________ * Social Security number is required to make the change, but will not appear on a certified copy of the birth record. *********************************************************************** 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
***********************************************************************
TO CHANGE THE CHILD'S NAME
If there is any change in the child's name from that originally recorded on the
birth record, please indicate the name change below. Please indicate if the mother
of the child wishes to have her name changed due to marriage.
Child's Full Name at Birth:
_______________________
_____________________________
_____________________
First
Middle
Last
Child's Full Name as You Want it to Appear on the New Birth Record:
_______________________
_____________________________
_____________________
First
Middle
Last
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A SIGNATURE IS REQUIRED TO PROCESS THE APPLICATION.
IF THE DOCUMENTATION IS A COURT ORDER, THE MOTHER'S SIGNATURE IS NEEDED WHEN REQUESTING A
NAME CHANGE FOR THE CHILD.
IF THE DOCUMENTATION IS AN AFFIDAVIT OF PARENTAGE, BOTH PARENTS' SIGNATURES ARE REQUIRED
WHEN REQUESTING A NAME CHANGE FOR THE CHILD.
Signature of Person
Requesting Change: ____________________________________________
Date: ________________________
Other Signature:
_______________________________________________
Date: ________________________
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PAYMENT
The fee for adding the father's name and information to 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.".
| Application Fee (Non-Refundable) | $26.00 | $ __________ | |
| Includes One Certified Copy of the Record | |||
| __________ Additional Certified Copies (Each) | $ 5.00 | $ __________ | |
| ************************************************************* | |||
| TOTAL ENCLOSED | $ ___________ |
|---|
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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-0848 Rev 06/2001 MCL 333.2824(4),
333.2872(1) and 333.2891(9)(a)
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END OF THE WRITTEN APPLICATION