APPLICATION TO CORRECT OR CHANGE A MICHIGAN BIRTH RECORD
                        (FOR A PERSON AGE SIX YEARS OR OLDER)

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 CORRECTION OR CHANGE OF 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 (            )__________________________________


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ELIGIBILITY

To be eligible to correct or change a birth record, you must be the person named on the record and at least 18 years old, a parent named on the record, 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.  Please check the item that applies to you:

[    ]   PERSON NAMED ON THE 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

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REQUIRED DOCUMENTATION
You must include with this application, at least two (2) pieces of documentary evidence dated at least five (5) years ago that are obtained from different sources.   Exception: Only one (1) document dated five (5) years ago is required to correct the spelling of the first or middle name of the person named on the record.  Changes to certain information, such as names, date of birth and other key items, are subject to very specific supporting documentation.  If you need more information or have specirid questions, you may call our Changes Unit at (517) 335-8660.   The types of supporting documents that are usually acceptable are listed below:

Hospital records							Insurance documents
Statement from attendant at birth			Military records			
Early medical records						Marriage records
Court documents							Real estate documents
School records							Naturalization documents
Passport records							Baptismal records

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.

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INFORMATION 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

Is this person adopted:  [    ] Yes              [     ]  No
If adopted or birth name has been changed for any reason, other than a marriage, please indicate name change:
______________________________________________________________________________________

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A SIGNATURE IS REQUIRED TO PROCESS THE APPLICATION. 

WHEN A CHILD'S NAME IS BEING CHANGED DUE TO A MARRIAGE OF THE PARENTS NAMED ON THE RECORD, BOTH PARENT'S SIGNATURES ARE REQUIRED.

        Signature of Person
                  Requesting Change: ____________________________________________  

                  Date: ________________________

        Other Signature:   _______________________________________________

                  Date: ________________________

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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 and made payable to the "State of Michigan.".

DCH-0847 Rev. 06/2001 MCL 333.2871(1) and 333.2891(10)
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