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Blank Texas Certificate Birth PDF Form

The Texas Certificate Birth form is an official document used to request corrections to a birth certificate. It is essential for individuals seeking to amend inaccuracies or complete missing information on their birth records. Understanding the requirements and procedures outlined in this form is crucial for ensuring a smooth correction process.

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The Texas Certificate Birth form is a crucial document for anyone looking to correct or update information on a birth certificate. This form allows for various changes, including correcting errors made by hospitals, adding or removing parents' names, and even updating a child's sex or a parent's race. It's important to note that only specific individuals can apply for corrections, such as the person named on the certificate if they are over 18, or the parents if the child is underage. The application process requires careful attention to detail, as certain sections must be completed, signed, and notarized, with supporting documentation provided to validate the requested changes. Additionally, applicants must be aware of the associated fees and the submission process, which varies depending on whether they choose standard or expedited service. Failure to provide accurate information can lead to delays or denials, so understanding the requirements is essential for a smooth correction process.

Texas Certificate Birth Preview

TEXAS
Health
and
Human
Services
Texas
Department
.
of
State
Health
Services
Correcting a Birth Certificate
THIS FORM CANNOT BE USED TO CORRECT A RECORD BASED ON AN ADOPTION.
Who Can Apply for a Correction?
• The person named on the birth certificate, if at least 18 years of age.
• Parent(s) named on the birth certificate, if child is under 18 years of age.
• Legal guardian(s), managing conservator, or legal representative (proof required) of the person named
on the birth certificate.
• Hospital or medical facility where the person named on the birth certificate was born.
How Do I Make a Correction?
☐ Complete and sign this application. See pages 4 and 5.
☐ Section 1, 2, 5 and 6 MUST be completed. See pages 2 and 3 for how to complete Section 3 or 4.
☐ Everyone signing section 6 must sign before a notary public and ATTACH A COPY OF
THEIR VALID PHOTO ID(S).
☐ The application must be original. Photocopies, alterations, strike-through, or write overs will not be
accepted.
☐ Submit the appropriate documentation. See pages 2 and 3.
☐ Submit the appropriate fees. See fee schedule below.
For Frequently Asked Questions, go to: https://www.dshs.texas.gov/vs/faq/#correct.
For more information, go to: https://www.dshs.texas.gov/vs/requirements.aspx.
Where Do I Mail the Application?
Regular Mailing Instructions - Estimated processing time is 6-8 weeks.
See https://www.dshs.texas.gov/vital-statistics/processing-times for current times.
Please submit your application, supporting documents (if required) and fees to:
DSHS – Vital Statistics Section, P.O. Box 12040, Austin, TX 78711-2040.
Expedited Service Mailing Instructions - Estimated processing time is 20-25 business days.
The order and $5.00 processing fee must be sent to the Vital Statistics Section via an overnight mail
service such as: FedEx, Lone Star, or UPS.
Please submit your application, supporting documents (if required) and fees to:
DSHS-Vital Statistics Section, MC 2096, 1100 W. 49
th
Street, Austin, TX 78756.
FAILURE TO PROVIDE INFORMATION REQUESTED ON THIS FORM, MAY RESULT IN SIGNIFICANT
PROCESSING DELAYS AND/OR DENIAL OF YOUR APPLICATION.
Fees: How much must I submit?
Fee Schedule
Fee ($)
Qty (#)
Total ($)
Filing Fees (Select One):
O
Correction to Birth Certificate (Not required if child’s name change is in
same court order to add/replace/remove parent)
$15.00
=
O
Correction to Birth Certificate by adding/removing/replacing a parent
$25.00
=
O
New Birth Certificate based on child’s sex or parent’s race or color
See “Correcting the Child’s Sex or Parent’s Race or Color” on Page 3.
$25.00
=
For urgent requests, orders may be EXPEDITED by paying the below expedited processing fee AND
sending the order through an overnight mail service, such as: FEDEX, LoneStar, or UPS to: DSHS-Vital
Statistics Section, MC 2096, 1100 W. 49
th
Street, Austin, TX 78756.
O
Expedited processing Fee (per application)
$5.00
All orders are returned free of charge by USPS regular mail. For expedited return mail service, select
one of the overnight return shipping methods below.
O
Expedite Overnight Mail (shipping within USA)
$16.00
O
USPS Express Overnight Mail (shipping overnight to PO Box ONLY)
$22.95
=
Birth Certificate(s):
O
Certified Corrected Birth Certificate ($22.00 per copy)
$22.00
=
Grand Total
Fees may be combined in one check or money order made payable to DSHS – Vital Statistics
For the status of your request, contact VSS by telephone at 1-888-963-7111 or online at: https://www.dshs.texas.gov/orderstatus/.
Page 1 of 5 VS-170 (Rev. 8/24)
What type of correction are you requesting?
A correction to a birth record may be filed to complete or correct a record that is incomplete or proved by
satisfactory evidence to be inaccurate. You must complete pages 4 and 5 of this application and may need
to provide a supporting document (See Box#1). IF THE CHILD IS A MINOR AND BOTH PARENTS ARE ON
THE BIRTH RECORD, BOTH PARENTS MUST SIGN SECTION 6, unless otherwise specified in Box #1.
Box # 1: Document Checklist
I want to…
You will need one of the supporting
documents shown in Box # 2 below
Correct a hospital error before 1
st
birthday
(hospital must sign and submit application)
No documentation required.
Correct an error or omission made by the hospital after child’s 1
st
birthday
1 or 2
Add or correct child’s first or middle name, BEFORE child’s 1
st
birthday
Examples: Cindie to Cindy or “no name” to Kathie
No documentation required
Add or correct child’s first or middle name, AFTER child’s 1
st
birthday
Examples: Ann to Anne or Merie to Marie or “no name” to Ryan
1, 2, 3, 4, 5, 6, 7, 8, or 9
Correct spelling of child’s last name (all documents must be dated
PRIOR to birth of child unless providing a court order)
Example: Martines to Martinez
5, 10, 11, 12, 13, or 14
Correct child’s date of birth, place of birth, or time of birth
1, 2, or 5
Correct child’s sex due to proven incompletion or inaccuracy
1 or 2
Correct parent’s information
(parent must be currently listed on the birth certificate)
5, 10, 11, 12, 13, or 14
Correct mother’s residence address at the time of the child’s birth
1, 2, or 5
Adding a parent AND the parents were married BEFORE the child was
born (Both parents must sign Section 6 of this application in the
presence of a notary. A Hospital Representative cannot apply)
12
Change child's First,
Middle, Last name Example: Martinez to Brown
5
Remove information from birth record
5
Add/remove/replace a parent (A Hospital Representative cannot apply
for this correction)
See page 3, “Adding, Removing, or
Replacing a Parent’s Name”
Suggested Supporting Documents:
Documents must be original certified copies (no photocopies) on official letterhead or with an original
certification or seal unless otherwise specified below. Foreign documents, including notaries, must have an
apostille or legalization from the Foreign Country where the document was issued. All supporting
documents must match the requested correction(s) exactly and cannot be altered.
If an acceptable supporting document cannot be obtained, a court order to correct the information must be
submitted. If an item has already been amended once, a court order is required to amend the same item
again.
Box # 2: Supporting Documents
1
Hospital or medical record at birth (admission/discharge or worksheet)
2
Letter from Hospital or medical facility at birth identifying the error made and explaining correction needed
3
Baptismal certificate - Must be within first 5 years of birth
4
Numident printout from the Social Security Administration (SSA). Issued by the SSA, PO BOX 33022,
Baltimore, MD 21290-3022. Contact SSA at 410-965-1727 for fees and more information.
5
A certified copy of a court order affecting information shown on the birth certificate. Include all pages with
judge’s signature and seal of the court.
6
Elementary school record - Must be signed by custodian of school records based on earliest attendance.
7
Federal census record
8
School census record
9
Armed forces discharge papers (form DD 214) – Photocopy accepted
10
Birth certificate(s) of child’s parent(s)
11
Birth certificate of child’s older brother or sister
12
Certified copy of Parent’s Marriage license
13
Parent’s Naturalization Certificate (must include name change) Call the Immigration and Naturalization Service
(ICE) at 800-375-5283 to obtain information on how to secure this document.
14
Photocopy of Parent’s domestic passport or Parent’s foreign passport with U.S. Visa, permanent residency card or
employment authorization card.
Page 2 of 5
VS-170 (Rev. 8/24)
Adding, Removing or Replacing a Parent’s Name
A new birth certificate may be filed based on parentage to Add, Remove or Replace a parent on the birth
certificate. Complete Sections 1,2,4,5 and 6 of this application (pages 4 and 5). In addition, one of five
types of documentation must be presented as evidence to file the new birth certificate:
1. A certified copy of the certificate of marriage of the parents;
2. A copy of the Acknowledgment of Paternity (VS-159.1) filed with the Vital Statistics Section;
3. A certified copy of the court decree establishing parentage;
4. A copy of the Acknowledgment of Paternity Rescission (VS 158) filed with the Vital Statistics Section;
or,
5. A gestational agreement.
Box # 3: Adding, Removing or Replacing a parent’s name
I am/We are…
You need to complete this application and…
A mother not married during pregnancy and
not married now and wants to add a father
Or
A mother married within 300 days prior to the
birth of the child and wants to add a biological
parent who is not the spouse
(1) Both parents sign Section 6 of this application in
the presence of a notary; and,
(2) Complete an Acknowledgement of Paternity (Visit
the Office of the Attorney General, Paternity
Opportunity Program at
https://www.texasattorneygeneral.gov/cs/establishing-
paternity)
A mother not married during pregnancy but is
now married to the parent
(1) Both parents sign Section 6 of this application in
the presence of a notary; and,
(2) Provide a certified copy of your marriage license
A parent with a court order establishing
parentage / removing parent (only corrections
ordered in the court order will be completed)
Or
Parents with a gestational agreement
(1) One parent signs Section 6 of this application in
the presence of a notary; and,
(2) Provide a certified copy of the entire court order
(all pages) signed by a judge
Parents who have signed a State of Texas
Acknowledgment of Paternity (VS 159.1)
(1) Both parents sign Section 6 of this application in
the presence of a notary; and,
(2) Provide a copy of the signed Acknowledgement of
Paternity (VS-159.1).
A parent who has an Acknowledgement of
Paternity Rescission (VS 158) filed with the Vital
Statistics Section and wants to remove their
name from the birth certificate*
(1) One parent signs Section 6 of this application in
the presence of a notary; and,
(2) Provide a copy of the signed Acknowledgement of
Paternity Rescission (VS-158).
Certified documents submitted will be retained by VSS and placed in a sealed file. A court
order is required to unseal a file. Parents should keep copies of certified documents for their
records and future use before sending them to VSS.
* Once a parent is removed from the birth certificate, they are no longer a qualified applicant to
request a certified copy of the child’s newly corrected birth certificate.
Correcting the Child’s Sex or the Parent’s Race or Color
A new birth certificate may be filed that incorporates the corrected sex of the person named on the birth
certificate. It may also be filed on older records to remove the parent(s) “race or color”. The filing fee to
create a new birth certificate is $25.00. Complete Section 3 and check the bottom box requesting a new
birth certificate be filed. If the bottom box on Section 3 is not checked, the correction will be attached to
the original record as an addendum ($15.00 filing fee required).
Reviewing the certified copy of the amended birth record
Once the amendment has been filed, the certified copy of the birth certificate will describe the corrections
made below the image of the original birth record.
Page 3 of 5 VS-170 (Rev. 8/24)
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IMPORTANT: Photocopies, alterations, strike-through, or
write-overs in Section 1 through 6 will not be accepted.
Please use a new application if you make a mistake.
Birth Certificate Correction Application
Type or Print (please use blue or black ink ONLY)
Remittance No.____________
Section 1: What is Your Name? (Applicant’s Information)
Name (First, Middle, Last):
Address (Mailing Address, City, State, Zip):
Email Address:
Telephone # (daytime)
( ) -
Your relationship to Person named on the birth certificate: ☐Parent ☐Self ☐Hospital Representative
☐Legal guardian(s) or Managing Conservator ☐Legal Representative (proof required)
>>>>>>>A COPY OF THE APPLICANT’S VALID PHOTO ID MUST BE ATTACHED<<<<<<<
Section 2: Birth Certificate Information
Enter information as it appears on the current birth certificate (before corrections).
Birth Certificate Number, if known:
142 - -
Child’s First Name:
Middle Name:
Last Name:
Date of Birth:
Sex:
Place of Birth (City or town)
(County)
(State)
TEXAS
Full Maiden Name (First, Middle, Last) of Parent 1:
Full Maiden Name (First, Middle, Last) of Parent 2:
Section 3: What do you want to correct?
If you are adding, removing or replacing a parent, complete Section 4.
List items to be added,
corrected or removed
What is on the birth certificate
now?
What should the birth certificate say?
Example: Child’s First Name
Not Shown
Tara
Example: Date of Birth
August 2, 2010
August 12, 2010
If you have a certified court order granting a name change only (not changing parentage), complete the information
below.
Court Ordered Name Change
First Name:
Middle Name:
Last Name:
Check box (if applicable): We are/I am requesting a new birth certificate be filed to incorporate the
correction to the child’s sex or remove the parent’s race or color.
Page 4 of 5 VS-170 (Rev. 8/24)
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Section 4: Add, Remove or Replace a Parent
If you want to add, remove or replace the name of a parent, please fill out this section.
I am requesting to:
Add Remove Replace
CHILD’S NAME ON NEW RECORD (Even if it will remain the same) If changing child’s first or middle name,
birth certificate correction procedures on page 2 apply.
First Name:
Middle Name:
Last Name(s):
Suffix:
INFORMATION FOR PARENT 1 (Even if it will remain the same)
Title (check one):
Mother Father Parent
Full Name (Full Maiden Name Prior to First Marriage)
First Name:
Middle Name:
Last Name(s):
Suffix:
Date of Birth
Place of Birth
Month: / Day: /Year:
State or Foreign Country:
INFORMATION FOR PARENT 2 (Even if it will remain the same) If only 1 parent will remain on the birth
certificate, leave this information blank.
Title (check one):
Mother Father Parent
Full Name (Full Maiden Name Prior to First Marriage)
First Name:
Middle Name:
Last Name(s):
Suffix:
Date of Birth
Place of Birth
Month: / Day: /Year:
State or Foreign Country:
Section 5: Would you like to request a birth certificate? Check one:
No, I would not like a certified copy of the corrected birth certificate.
Yes, I would like a certified copy of the corrected birth certificate. Number requested: _______
Please verify fees and quantity ordered in the fee box on Page 1.
Section 6: Affidavit
Please sign below in the presence of a notary public and ATTACH a copy of your valid Photo ID.
Applications without acceptable valid ID attached will not be processed.
Cross-outs or white-outs will VOID
your application.
WARNING: The Penalty for knowingly making a false statement in this form can be 2-10 years in prison
and a fine of up to $10,000. (Texas Health and Safety Code, Chapter 195).
Self, Parent 1, Legal Guardian, or Hospital Rep. >>>>>ATTACH A COPY OF YOUR VALID PHOTO ID<<<<<
Printed Name:
Signature:
Address:
City:
State:
Zip:
Notary Public, County Clerk, or other person authorized to administer oaths
Sworn to and subscribed before me, this ______ day of ____________ 20______.
[Stamp or Seal]
Signature:
Printed name and title:
Parent 2 or Legal Guardian 2, if applicable:
>>>>>ATTACH A COPY OF YOUR VALID PHOTO ID<<<<<
Printed Name:
Signature:
Address:
City:
State:
Zip:
Notary Public, County Clerk, or other person authorized to administer oaths
Sworn to and subscribed before me, this ______ day of ____________ 20______.
[Stamp or Seal]
Signature:
Printed name and title:
Page 5 of 5 VS-170 (Rev. 8/24)
⇓ Texas Certificate Birth PDF

Document Specs

Fact Name Details
Eligibility to Apply Only the person named on the birth certificate (if 18 or older), parents, legal guardians, or the hospital can apply for a correction.
Application Requirements The application must be original. Photocopies or alterations will not be accepted.
Notarization Requirement All signatures in Section 6 must be notarized, and valid photo ID must be attached.
Processing Time Regular processing takes 6-8 weeks, while expedited service takes 20-25 business days.
Filing Fees Fees range from $15 to $25 depending on the type of correction requested.
Supporting Documents Original certified documents are required to support the correction request.
Governing Law Texas Health and Safety Code, Chapter 195 governs the process for correcting birth certificates.
Types of Corrections Corrections can include name changes, date of birth adjustments, and changes to parent information.
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