Form Vr172 – Fill Out and Use This PDF

Register to vote: http://www.nyccfb.info/public/VRC/registeringToVote.aspx?sm=public_rtv

VR 172 (Rev. 01/15)

DEPARTMENT OF HEALTH AND MENTAL HYGIENE • OFFICE OF VITAL RECORDS

Correcting a

Birth Certificate

Who Can Apply for a Correction?

●The person named on the certificate if he/she is at least 18 years old.

●Parents or legal guardians of the person less than 18 years of age named on the certificate.

Anyone applying must submit current (not expired), signed photo identification. If both parents’ names appear on the

record, both must sign application and submit photocopy of each parent’s identification. We accept photocopies of identification with mailed applications. Photocopies must be clear and include front and back of identification.

If the hospital where your child was born made a mistake on the birth certificate, you must submit your application and the newborn certificate you received to the hospital if the child is less than 1 year of age.

How Do I Make a Correction?

●Submit original documents (for example, a marriage record or a religious document) on official letterhead or with an original seal depending on the kind of correction you want (photocopies, altered documents or notarized copies are not accepted). See Box 1 on Page 2.

●Submit one photocopy with each of the original documents.

●Complete and sign the application.

●Pay a non-refundable $40 processing fee for most corrections plus $15 per copy for each new certificate.

●If you are applying by mail, include a self addressed, stamped envelope so that we can return your documents.

What Kind of Document Do I Need?

You must send original documentation on letterhead or certified copies with your application. Certified copies are documents issued by a government office that has a raised seal, like birth certificates or marriage certificates. Usually a fee is required to obtain a certified copy from an office or agency. Notarized copies, photocopies or altered documents are unacceptable.

Generally, a document must have been established prior to the child’s 7th birthday or it must be at least 10 years old. This helps us establish that the documentation you are submitting is legitimate. Documents should include the following:

● Child’s Name

● Listed Date of Birth

● Parent’s Name(s)

If your documents are in a language other than English, you must obtain an official translation of documents needed. Foreign consulates often will translate official documents for you. We also accept translations from established translation services. If you can’t provide the required documents, ask for help by calling 311.

FEES: How Much Does It Cost to Make a Correction?

The Health Department charges a non-refundable $40 application processing fee to make most corrections. Where fees apply, the application is only $40 even if more than one item is corrected.

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Box #1: Document List

								You will need one of the
		I Want To . . . (please check all that apply)
								documents below:
		Where fees apply, the application is only $40 even if more than one item is corrected.
								(see box 2)
		□ Correct a hospital error before 1st birthday (Please return application to hospital of birth)						No Documentation Required
		□ Correct an error or omission made by the hospital after child’s 1st birthday						2
		□ Correct child’s first or middle name, or add a child’s middle name BEFORE child’s 1st birthday						1, 3, 4, 5, 7 or 8
			Example: Dabid to David
		□ Correct first or middle name after 1st birthday.
								1, 3, 4, 5, 6, 7 or 8
		□ Add child’s first and middle name BEFORE child’s 1st birthday at the hospital of birth. No Fee						No Documentation Required
		□ Add a child’s first and middle name BEFORE 60 days of birth at DOHMH. No Fee						No Documentation Required
		□ Add a child’s first and middle name AFTER 60 days of birth.			□ Child less than 1 year			No Documentation Required
					□ Child over 1 year			1, 3, 4, 5, 6, 7 or 8
		□ Correct spelling of child’s last name (all documents must be dated PRIOR to birth of child)						10, 11, 12 or 13
		□ Correct child’s date of birth or sex						2
		□ Correct gender marker on birth certificate						Go to nyc.gov/vitalrecords for
								documentation required or call 311
		□ Correct spelling of parent’s information						9, 11 or 16
		□ Add name of another parent. Fee may apply. See fee section on bottom of page 1.						See Box 3 below
		□ Legal name change						12 with a name change
			Example: June to Edna					petition or 14
		□ Remove information from birth record						15
Box #2: List of Documents Accepted by the New York City Health Department
	1.		Letter from hospital where child was born including child’s	11.	Parent’s marriage record if parents were married before child’s
			correct name, date of birth, and parent’s name(s).		birth, last name corrections only (New York State does not
	2.		Letter from hospital admitting error.		recognize common law marriage).
	3.		Immunization record showing child’s name, date of birth, parent	12.	Parent’s naturalization certificate.
			name and the health care facility’s stamp.	13.	Birth certificate of an older brother or sister.
	4.		First census record taken after birth or census taken at least	14.	Certified Court Order which must include Date of Birth, Place of
			10 years ago (federal or state).		Birth and Certificate Number. You must go to Civil Court if you live
	5.		Letter from physician including treatment dates.		in NYC. Outside of NYC go to the appropriate court for this action.
	6.		School admission letter including date of admission.	15.	Usually requires a State Supreme Court Order unless the
	7.		Religious document.		hospital of birth made a mistake. If hospital made the error
	8.		Child’s life insurance policy.		request an admission in writing from the hospital.
	9.		Parent’s birth certificate (for corrections of child’s last name, the	16.	Parent’s birth record, older child’s birth record, religious
			certificate of the parent who has the child’s last name is required).		document or naturalization certificate. Marriage Record may
	10.		Parent’s passport.		be used for last name only.

Box #3: Adding Another Parent’s Name

Adding the name of another parent to a birth certificate, typically the father, depends on the marital status of the mother. Married same sex parents also can add their names to birth certificates. See table below to find out what you must do.

Marriage records or other documents must be submitted with the application. In cases where the parent has been married more than once, divorce records also must be submitted.

New York State recognizes same sex marriage performed in other states, Washington DC and abroad. It does not recognize common law marriage.

How Do I Add the Name of Another Parent? Look below to see which description fits your situation.

	Marital Status of Parent		You Need To:
	Mother not married during pregnancy and not married now		Complete an Acknowledgment of Paternity Form (DSS 4418)
	and wants to add a father		or go to Family Court for an Order of Filiation
	Mother married during pregnancy, want to add spouse’s name		If you were married at the time of your child’s birth,
	(male or female)		complete Section 4 on page 4 of the application
	Mother not married during pregnancy but now married to		Complete an Acknowledgment of Paternity form (DSS 4418)
	biological father		or go to Family Court for an Order of Filiation
	Mother married after birth but not to biological father		Go to Family or Supreme Court for an Order of Adoption
	Mother married to a male during pregnancy but not to biological father		Go to Family Court for an Order of Filiation
	Same Sex Parents (Female) not married		Go to Family or Supreme Court for an Order of Adoption
	Same Sex Parents (Male) married or not married		Go to Family or Supreme Court for an Order of Adoption

Acknowledgment of Paternity Forms (LDSS 4418) are available in the Corrections Department lobby and enclosed with all applications ordered by mail or go to https://www.childsupport.ny.gov/dcse/pdfs/4418.pdf

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VR 172 (Rev. 01/15)

DEPARTMENT OF HEALTH AND MENTAL HYGIENE • OFFICE OF VITAL RECORDS

Reference

No.

Birth Certificate Correction Application Form

Please use blue or black ink ONLY.

Section 1: What Is Your Name? You Must Be At Least 18 Years Old

		Area Code	Telephone Number		Marital	□ Single	□ Divorced
	Wireless	□ AT & T □ T-Mobile	□ Sprint	□ Verizon	Partnership	□ Married	□ Widowed
					Status
	Carrier
		□ Other _______________________________________				□ Separated	□ Domestic Partnership

Section 2: Birth Certificate Information

Name of Hospital, birthing center or if born at home, street address, city, state, ZIP)

Section 3: What Do You Want To Correct?

Please use one line per correction. We cannot accept white-outs or cross-outs; if you make a mistake, please use a new application form.

List items to be corrected	Write errors as they appear on birth record	What should it say on birth record?
Example: Child’s First Name	Not Shown	Michael
Example: Date of Birth	October 16, 2009	October 19, 2009

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Section 4: Second Parent Information

If you want to add the name of another parent, please fill out this section. You must have been married prior to the birth of the child. See “How Do I Add the Name of Another Parent?” on page 2.

Name of Second Parent

Section 5: Sign Your Application

Please sign the form where appropriate. If both parents’ names appear on the birth certificate, both must sign if the child is under 18.

	Signature of Mother/Parent/Legal Guardian			Date
	Signature of Father/Parent/Legal Guardian			Date

Your Signature (if you are 18 or older and are requesting a correction of your own birth certificate)

Warning! No person shall make a false, untrue or misleading statement or forge the signature of another on an application required to be prepared pursuant to the New York City Health Code. A violation of the Health Code shall be punishable as a misdemeanor.

How to Submit Your Application:

A copy of the corrected certificate costs $15. This fee is waived if you enclose a certified copy of a certificate purchased within the past 3 months and want to exchange it for a corrected certificate.

Figure out the cost: Processing Fee: $40 (See page 1 for applicable fees.	$ _________
( not all corrections have a fee.)
Copy Fee: number of copies _________ X $15 each	$ _________
Total Amount Enclosed:	$ _________

Please make your check or money order payable to the: New York City Department of Health and Mental Hygiene. Cash not accepted. Walk-in customers may pay using a credit or debit card.

Make certain you have enclosed everything necessary (please check all that apply):

Submitting false identification is a crime and violators are subject to prosecution.

MAIL TO: NYC Department of Health and Mental Hygiene

Corrections Unit

125 Worth Street, Room 144, CN-4

New York, NY 10013

FOR HEALTH DEPARTMENT USE ONLY

Certification by the NYC Department of Health and Mental Hygiene

This is to certify that I have examined the original record that this application seeks to correct, and any original documents required to verify the correction. There are no omissions or apparent errors in the original record that have not been covered. Therefore, the application is approved.

							DOCUMENT
							NO.
	Signature of Deputy City Registrar			Date
VR 172 (Rev. 01/15)
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