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 LEGAL NAME CHANGE
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 Legal Name Change:
__________________________________________________________________
Mailing Address: _____________________________________________________
City/State/Zip________________________________________________________
Daytime phone number to contact you:
Area Code ( )
_______________________________________________
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ELIGIBILITY
To be eligible to request a legal name change on a birth record, you must be the
person named on the record and at least 18 years old, a parent named on the record, or the
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.
[ ] PERSON NAMED ON RECORD (must be at least 18
years old)
[ ] PARENT NAMED ON RECORD
[ ] LEGAL GUARDIAN OF THE PERSON(S) NAMED ON THE RECORD
[ ] LEGAL REPRESENTATIVE OF THE PERSON(S) NAMED ON THE
RECORD
Court order or true
copy is attached (required to process application):
[ ] YES
(Court order will be returned to
you)
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NAME AS INDICATED BY COURT ORDER
____________________
_________________
______________________
First
Middle
Last
***********************************************************************
INFORMATION BELOW IS NEEDED TO LOCATE BIRTH RECORD TO BE CHANGED
Date of Birth: ________________________________________________________
Month
Day
.
Year
Name at Birth:
_________________ _____________________
_______________________
First
Middle
Last
Gender:
[ ] Male
[ ] Female
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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Is this person adopted?: [ ] Yes [ ] No
If adopted or name has been changed for any reason
other than marriage, please indicate name change:
________________________________________________________
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A SIGNATURE IS REQUIRED TO PROCESS THE APPLICATION.
Signature of Person
Requesting Change: ____________________________________________
Date: ________________________
***************************************************************************
PAYMENT
The fee for 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.".
| 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-0850 Rev. 06/2001 MCL 333.2872(2) and
333.2891(9)(a) and (12)
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END OF THE WRITTEN APPLICATION