APPLICATION TO CORRECT OR CHANGE A MICHIGAN BIRTH RECORD
                 (FOR A CHILD LESS THAN ONE YEAR OLD)

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 (            )__________________________________


***********************************************************************

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


***********************************************************************


DOCUMENTATION IS "NOT" REQUIRED FOR THE FOLLOWING CHANGES:

[    ]  Correct, add or change the first or middle name of the child.
[    ]  Correct the spelling of the child's last name.
[    ]  Add a parent's first or middle name if originally omitted.

REQUIRED DOCUMENTATION

Any other changes than those items listed above require documentary evidence.   Some examples might be hospital records, medical records, statement from attendant at birth, baptismal records, insurance documents, etc.  If you need more information or have specific questions, you may call the Changes Unit at (517) 335-8660.

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.


***********************************************************************

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


***********************************************************************

A SIGNATURE IS REQUIRED TO PROCESS THE APPLICATION. 
WHEN TWO PARENTS ARE NAMED ON THE RECORD, BOTH PARENTS' SIGNATURES ARE REQUIRED TO CORRECT, ADD OR CHANGE A CHILD'S NAME.

       Signature of Person
                  Requesting Change: ____________________________________________  

                  Date: ________________________

      Other Signature:   _______________________________________________

                  Date: ________________________

***********************************************************************


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 payable to the "State of Michigan.".