APPLICATION TO CORRECT OR CHANGE A MICHIGAN BIRTH RECORD
PUBLIC AGENCY USE ONLY
(Must be legal guardian of the child)

MAIL APPLICATION WITH PAYMENT TO:
VITAL RECORDS CHANGES
P.O. Box 30691
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

PUBLIC AGENCY REQUESTING CORRECTION OR CHANGE       
Please provide public agency 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.  

Agency Name: ______________________________________________________

Agency Representative: _______________________________________________

Mailing Address: _____________________________________________________

City/State/Zip________________________________________________________

Daytime phone number to contact you: 

Area Code (            ) _______________________________________________

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ELIGIBILITY
To be eligible to make a correction or change to a Michigan birth record, you must be a public agency that is named as legal guardian for this child. Please provide a copy of the court document that appointed you legal guardian.

Copy of court document that appointed your agency legal guardian is attached:   [   ] Yes

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

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REQUIRED DOCUMENTATION

Documentation is required to make most corrections or changes to a Michigan birth record. You must include with this application, at least two (2) pieces of documentary evidence that are obtained from different sources to support the correction or change you are requesting.

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

1.________________________________________________________________________

2.________________________________________________________________________

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.


Signature of Person Requesting Change:


________________________________________    Date:_____________


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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). ****************************************************************************************
FOR OFFICE USE ONLY - DO NOT WRITE IN THIS AREA

DCH-0853 Rev 06/07/00 MCL 333.2871(1) and 333.2891(11)(e)
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END OF THE WRITTEN APPLICATION