VS-24 Form PDF Details

The form VS-24 includes an affidavit statement that must be signed by two persons certifying that they have personal knowledge of the above facts and that the information given above is true and correct. It becomes a part of the official record and must be completed in black ink without any erasures, whiteouts, photocopies, or alterations.

There is a fee associated with amending the record, which varies depending on the circumstances, and the form should be sent to the California Department of Public Health Vital Records - Amendments for processing.

QuestionAnswer
Form NameForm VS-24
Form Length2 pages
Fillable?Yes
Fillable fields75
Avg. time to fill out15 min 34 sec
Other namesform vs24, vs 24 form, vs 24c california, ca form vs 24 c

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AFFIDAVIT TO AMEND A RECORD

_______________________________

NO ERASURES, WHITEOUTS, PHOTOCOPIES,

______________________________

STATE FILE NUMBER

 

OR ALTERATIONS

LOCAL REGISTRATION NUMBER

BIRTH

DEATH FETAL DEATH

 

TYPE OR PRINT CLEARLY IN BLACK INK ONLY – THIS AMENDMENT BECOMES AN ACTUAL PART OF THE OFFICIAL RECORD

PART I INFORMATION TO LOCATE RECORD

INFORMATION AS IT APPEARS ON CURRENT RECORD

 

1A. NAME—FIRST

1B. MIDDLE

 

 

 

1C. LAST

 

 

 

 

 

 

 

 

 

2. SEX

3. DATE OF EVENT—MM/DD/CCYY

4. CITY OF EVENT

 

5. COUNTY OF EVENT

 

 

 

 

 

 

 

 

6. FULL NAME OF PARENT AS STATED ON CURRENT RECORD

 

 

7. FULL NAME OF PARENT AS STATED ON CURRENT RECORD

 

 

 

 

 

 

 

 

PART II STATEMENT OF CORRECTIONS TO BIRTH, DEATH, OR FETAL DEATH RECORD

LIST ONE ITEM PER LINE

8.ITEM

NUMBER TO BE

CORRECTED

9. INCORRECT INFORMATION THAT APPEARS ON CURRENT RECORD

10. CORRECTED INFORMATION AS IT SHOULD APPEAR

REASON FOR CORRECTION

11.

AFFIDAVITS

AND

SIGNATURES

TWO

PERSONS

MUST SIGN

THIS FORM TO

CORRECT A

BIRTH, DEATH,

OR FETAL

DEATH

RECORD

We, the undersigned, hereby certify under penalty of perjury that we have personal knowledge of the above facts and that the information given above is true and correct.

12A. SIGNATURE OF FIRST PERSON12B. PRINTED NAME12C. TITLE/RELATIONSHIP TO PERSON IN PART I

12D. ADDRESS (STREET and NUMBER, CITY, STATE, ZIP)

 

12E. DATE SIGNED—MM/DD/CCYY

 

 

 

13A. SIGNATURE OF SECOND PERSON

13B. PRINTED NAME

13C. TITLE/RELATIONSHIP TO PERSON IN PART I

 

 

13D. ADDRESS (STREET and NUMBER, CITY, STATE, ZIP)

 

13E. DATE SIGNED—MM/DD/CCYY

STATE/LOCAL

REGISTRAR

USE ONLY

14. CDPH - VITAL RECORDS OR LOCAL REGISTRAR

15. DATE ACCEPTED FOR REGISTRATION

STATE OF CALIFORNIA, DEPARTMENT OF PUBLIC HEALTH - VITAL RECORDS

FORM VS 24 (REV. 04/20)

APPLICATION TO AMEND A RECORD

TYPE OR PRINT CLEARLY IN BLACK INK ONLY

NO ERASURES, WHITEOUTS, PHOTOCOPIES, OR ALTERATIONS

If an acceptable application to amend the record is registered within one year of the date of the event, there is no processing fee; however, there is a fee required for a certified copy.

Enclosed is the fee of $___________________________ for a certified copy of the newly amended record.

If an acceptable application to amend the record is registered one year or more after the date of the event, there is a fee for filing the affidavit, which includes one certified copy. There is a fee for each additional certified copy. Please contact your Local Registrar, County Recorder, or the State Registrar for the current fees, or visit our website at www.cdph.ca.gov.

Enclosed is the fee of $___________________________ for filing the affidavit and one certified copy of the newly amended record.

Enclosed is the fee of $___________________________ for an additional certified copy(ies) of the newly amended record.

______________________________________________

______________________________________________________________________

Printed Name of Applicant

 

Mailing Address of Applicant

Telephone Number (

) ________________________

______________________________________________________________________

Email Address: _________________________________

City, State, ZIP Code

 

GENERAL INFORMATION

1.The original certificate cannot be altered.

2.This amendment becomes a part of the original record, so please type or print clearly in black ink only.

3.Please submit original amendment form only. Photocopies of the amendment form will be rejected.

4.Your certified copy will include a copy of the original certificate with a copy of the amendment.

5.The certified copy of the certificate and the attached amendment must remain together for the certified copy to be valid.

READ INSTRUCTIONS CAREFULLY BEFORE COMPLETING THE FORM

1.A Notarized Sworn Statement is required when requesting a certified authorized copy of the amended certificate. For more information please visit our website at www.cdph.ca.gov.

2.This form becomes a part of the original record – type or print clearly in black ink only.

3.No erasures, whiteouts, photocopies, or alterations allowed.

4.Complete Part I, Items 1 – 7, with the information as it appears on the current certificate.

5.Enter the certificate item number(s) to be corrected, either from the original or subsequent amendment, in Part II—Item 8. List one item per line.

6.Enter the incorrect information that appears on the current certificate in the line(s) provided below Item 9.

7.In Item 10, enter the correct information as it should appear for each item listed in Item 9.

8.Enter the reason for the correction in Item 11.

9.Read the affidavit statement. Two persons who are certifying to the statement of corrections must sign the form.

10.Do not write in Items 14 or 15. This space is reserved for State or Local Registrar use only.

11.Make check or money order payable to CDPH - Vital Records. When the paperwork is properly completed and signed by two parties, return this form, together with the required fee(s), to:

California Department of Public Health

Vital Records - Amendments - MS 5105

P.O. Box 997410

Sacramento, CA 95899-7410

How to Edit Form VS-24 Online for Free

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The next segments are contained in the PDF file you'll be filling out.

form vs24 gaps to fill in

Write the necessary information in the REASON FOR CORRECTION, AFFIDAVITS AND SIGNATURES, TWO PERSONS MUST SIGN THIS FORM TO, We the undersigned hereby certify, A SIGNATURE OF FIRST PERSON, B PRINTED NAME, C TITLERELATIONSHIP TO PERSON IN, D ADDRESS STREET and NUMBER CITY, and E DATE SIGNEDMMDDCCYY box.

Finishing form vs24 stage 2

Provide the significant data in the TWO PERSONS MUST SIGN THIS FORM TO, STATELOCAL REGISTRAR USE ONLY, A SIGNATURE OF SECOND PERSON, B PRINTED NAME, C TITLERELATIONSHIP TO PERSON IN, D ADDRESS STREET and NUMBER CITY, E DATE SIGNEDMMDDCCYY, CDPH VITAL RECORDS OR LOCAL, DATE ACCEPTED FOR REGISTRATION, STATE OF CALIFORNIA DEPARTMENT OF, and FORM VS REV box.

Filling out form vs24 part 3

Spell out the rights and obligations of the sides inside the paragraph If an acceptable application to, Enclosed is the fee of for a, If an acceptable application to, Enclosed is the fee of, for filing the affidavit and one, Enclosed is the fee of, for an additional certified, Printed Name of Applicant, Telephone Number, Email Address, City State ZIP Code, GENERAL INFORMATION, and The original certificate cannot.

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Fill in the form by taking a look at all these areas: A Notarized Sworn Statement is, For more information please visit, This form becomes a part of the, No erasures whiteouts photocopies, Complete Part I Items with the, Enter the certificate item, List one item per line, Enter the incorrect information, In Item enter the correct, Enter the reason for the, Read the affidavit statement Two, Do not write in Items or This, Make check or money order payable, two parties return this form, and California Department of Public.

Filling out form vs24 step 5

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