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 NAME CHANGES
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 Name Changes:
___________________________________________________________________
Mailing Address: _____________________________________________________
City/State/Zip________________________________________________________
Daytime phone number to contact you:
Area Code (
)
________________________________________________________
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ELIGIBILITY
To be eligible to change names on a Michigan birth record
due to a marriage, you must be the person named on the record and at least 18 years old,
parent named on the record, legal guardian of the person(s) named on the record, or
legal representative of the person(s) named on the record. Please check the item
that applies to you:
[ ] PERSON NAMED ON RECORD
(must be at least 18 years old)
[ ] 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
The change of mother's and child's names on the birth record
requires evidence of a marriage to the father named on the record.
[ ] A copy of the marriage record is
attached. *
* 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
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TO CHANGE THE CHILD'S NAME OR MOTHER'S NAME
DUE TO A MARRIAGE
If there is any change in the child's or mother's name from
that originally recorded on the birth record, please indicate the name change below.
CHILD'S FULL NAME AS YOU WANT IT TO APPEAR ON THE NEW BIRTH RECORD:
____________________
_______________________ _________________________
First
Middle
Last
MOTHER'S CURRENT FULL NAME:
____________________ ______________________
_________________________
First
Middle
Last
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A SIGNATURE IS REQUIRED TO PROCESS THE APPLICATION.
BOTH 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 amending mother's and child's names on a
Michigan birth record due to a marriage 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