Birth Record Correction Declaration Form
Submit your request to correct information on an existing birth record. Please provide accurate details to ensure your request is processed efficiently.
Full Name on Birth Record
*
First Name
Last Name
Date of Birth on Record
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Place of Birth (City, State/Country)
*
Parent/Guardian Names on Record
*
Correction Requested
*
Please Select
Name Correction
Date of Birth Correction
Place of Birth Correction
Parent/Guardian Name Correction
Other
Current Information (as it appears on the record)
*
Correct Information (what it should be)
*
Reason for Correction / Supporting Details
*
Your Contact Email
*
example@example.com
Submit Correction Request
Should be Empty: