Minor Birthdate Change Request Form
Use this form to request a correction to a minor's birthdate on an existing record. Please provide accurate information to support your request.
Minor's Full Name
*
First Name
Last Name
Minor's Current Birthdate on Record
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Requested Correct Birthdate
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Correction
*
Parent or Guardian Full Name
*
First Name
Last Name
Relationship to Minor
*
Please Select
Parent
Legal Guardian
Other
Contact Email Address
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Upload Supporting Document(s)
*
Upload a File
Drag and drop files here
Choose a file
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Additional Comments or Explanation
Submit Request
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