Ph 1673 Form – Fill Out and Use This PDF

TENNESSEE DEPARTMENT OF HEALTH

OFFICE OF VITAL RECORDS

APPLICATION FOR NEW CERTIFICATE OF BIRTH

BY SUBSEQUENT MARRIAGE OF PARENTS

Read instructions on the back before completing this form.

SECTION I				INFORMATION ON CHILD’S ORIGINAL BIRTH CERTIFICATE
Full Name of Child
			First	Middle			Last
Date of Birth					Sex
Place of Birth
	City			County			State
SECTION II				AFFIDAVITS OF PARENTS

I hereby certify, on oath, that I am the biological (natural) father of the child named in Section I and I was married to the mother of this child on_____________________________________ at _______________________________________.

DateCountyState

Father’s Signature __________________________________________________________________________________

Seal	Subscribed to and sworn before me this the _________ day of ________________________, 20_______
	____________________________________ My commission expires _____________________, 20_______
	Signature of Notary

I hereby certify, on oath, that I am the mother and that ______________________________________________________

is the biological (natural) father of the child named in Section I.Print Father’s Full Name

Mother’s Signature __________________________________________________________________________________

Seal

Subscribed to and sworn before me this the _________ day of ________________________, 20_______

____________________________________ My commission expires_____________________, 20_______

Signature of Notary

SECTION III

INFORMATION FOR NEW CERTIFICATE

Full Name of Child _____________________ _______________________

_________________________________

(As it should appear on new certificate) First

Middle

Last

FATHER OF CHILD

MOTHER OF CHILD

Full Name

Full Legal Name

Date of Birth

Maiden Surname

Birthplace

Date of Birth

State or Foreign Country

Social Security Number

Social Security Number

Residential Address

Residential Address

City	State	Zip Code	City	State	Zip Code
PH-1673 (Rev. 05/15)					RDA 10112

INSTRUCTIONS

1.According to Tennessee Law (Tennessee Code Annotated 36-2-304) a man is presumed to be the father of a child if, after the child’s birth, he and the mother have married and he has consented in writing to be named the child’s father on the birth certificate. By completing this form and signing it in the presence of a notary public, the mother and the father agree the man is the father and that his name should be listed on the child’s birth certificate.

2.If any other man is already listed as the child’s father on the birth certificate, a court order must refute that man as father so that his name can be removed from the birth certificate.

3.If the man signing this application is already named as the father on the child’s birth certificate, a new birth certificate will not be prepared.

4.This is a legal form. Please read it and complete it carefully. Do not sign this form if you do not understand what it means.

5.Use black ink. Do not use any white out or erasures or the form will not be accepted.

•Complete Section I with information that appears on the child’s original birth certificate.

•Complete Section II under oath in the presence of a notary public.

•In Section III enter the child’s name exactly as you want it to be shown on the child’s new birth certificate. The child’s given names (first and middle names) must remain as shown on the original birth certificate. The last name may be changed to that of the father. Provide the personal information about the parents to be entered on the child’s new birth certificate.

6.Return this application to:

TENNESSEE VITAL RECORDS OFFICE ANDREW JOHNSON TOWER, 1ST FLOOR 710 JAMES ROBERTSON PARKWAY NASHVILLE, TN 37243

•Enclose a certified copy of the parents’ marriage certificate if the parents did not marry in Tennessee. If the parents were married in Tennessee within the past 50 years, you may enclose either a certified copy of the marriage certificate or information on the date and place of marriage so that staff can locate the marriage certificate.

•Enclose a fee of $30.00 in the form of a check or money order made payable to Tennessee Vital Records for a certified long form copy of the new birth certificate. Additional copies are $15.00 each.

7.Once this form has been completed and filed with the Tennessee Vital Records Office, a court order will be required to make changes in the child’s name or make changes in the parentage of the child.

8.After the Tennessee Vital Records Office determines that this application form is complete, that the child has a Tennessee birth certificate, that no father is listed on the child’s birth certificate, and that the marriage certificate copy is acceptable, a new birth certificate will be prepared for the child. You will be sent the certified copies of the new birth certificate, which you ordered. This application form will be placed in a sealed file and cannot be opened or released except by court order.

9.If you have questions, contact the Tennessee Vital Records Office at (615) 532-2685.

PH-1673 (Rev. 05/15)

RDA 10112