Birth Certificate Modification Application

North Carolina Department of Health and Human Services

Division of Public Health • Office of Vital Records

http://vitalrecords.nc.gov/vitalrecords

Mail: Attn: Amendments Unit

1903 Mail Service Center

Raleigh, NC 27699-1900

Location: 225 North McDowell St.

Raleigh, NC 27603-1382

Birth Certificate Modification Application

To apply for modification (amendment or correction) to birth certificate:

• Complete this form and mail along with the required supporting documents (see pages 2-8) and a certified check or money order for $39 (amendment, correction, paternity

or legitimation) payable to N.C. Vital Records.

• If applicants cannot supply the required evidence or identity to support the request, they must obtain a court order to support the request for modification.

• Personal checks and cash are not accepted.

• If the applicant requires more than one copy of the modified certificate, the applicant must order additional modified copies at https://vitalrecords.nc.gov/order.htm after

the modification has been made to the record.

• If the field that you are seeking to modify has been previously modified by the state, please note that you will be required to obtain a court order to modify the field. If you

are unsure of whether the field has been previously modified, you may submit a Request to Amend Form and the state will research this for you prior to your completion

of this application; however, please note that submission of the Request to Amend Form will add processing time.

• If the modification application is denied, the fees for records search and modification processing shall not be returned. Applications may be denied if they do not include

payment, a properly completed and notarized application, and the evidence and proof of identity and entitlement required on pages 2-8 of this application. If an application

is denied and the requestor wishes to apply again, a new application and fee payment shall be required.

• If you require more space in Part II for the fields you are requesting to modify, print and complete additional copies of page 1 of this application. Note that each completed

copy of page 1 of this application must be notarized.

• Enter the type of request you are submitting in the "Reason for Modification" box (e.g., legal name change, amendment, paternity, legitimation, adoption, etc.).

If you have questions, please call the North Carolina Office of Vital Records Amendments Unit at (919) 792-5986.

PART I – INFORMATION TO LOCATE RECORD

Name at Birth or Death ___________________________ ______________________________ ____________________________

First Middle

Date of Birth County of Birth

Did parents marry after the birth of the child?  Yes  No

Were parents married at time of birth?  Yes  No

Father/Parent

________________________________________________________________________________________________

First Middle Last If applies, Last Name Prior to First Marriage

Mother/Parent ________________________________________________________________________________________________

First Middle Last If applies, Last Name Prior to First Marriage

PART II – STATEMENT OF MODIFICATIONS TO BIRTH RECORD

INCORRECT INFORMATION

THAT APPEARS ON THE CERTIFICATE

CORRECTED INFORMATION

AS IT WOULD APPEAR ON THE CERTIFICATE

REASON FOR MODIFICATION: ______________________________________________________________________________

DOCUMENTARY EVIDENCE SUBMITTED: ____________________________________________________________________

I do solemnly swear that: (1) I am requesting that the birth record be modified; (2) I have personal knowledge of the correctness of the statements made in this

application and the evidence supplied to support the modification; (3) That the facts listed under the "incorrect information"

section of this application are incorrectly stated or

omitted on the birth record; (4) That the amendment requested under the "corrected information" section of this application will change the birth record so as to make it reflect the

true facts. Note: It is a felony violation of North Carolina Law (G.S. 130A-26A) to make a false statement on this application.

Street Address or Post Office Box City

State

ZIP code

_____________________________________________________________________

___________________________________

Last

________________________________________

Applicant 1 Name (Print)

____________________________________ _________

Applicant 1 Signature (Do not sign prior to appearance before notary public)

Date

State of _________________________________________ County of ______________________________________________

Sworn to and subscribed before me this the _____ day of ___________________________________________, 20____

My Commission Expires:

(Form DHHS 1578 - N.C. Vital Records 07/2022)

____________________________________________________________________________________

(

NOTARY

SEAL)

Relationship of Person(s) Applying for Modification(s)

(Area Code) Telephone Number

TO BE COMPLETED BY

NOTARY PUBLIC

Applicant 2 Signature (Do not sign prior to appearance before notary public)

___________________ _________________________________________________________________________________

___________________________________ ________________________________________

Date

_________

(

NOTARY

SEAL)

________________________________________

Applicant 2 Name (Print)

____________________________________

Identification Requirements

Due to identity theft and other fraudulent use of vital records, the person requesting a certificate is

REQUIRED to comply with the below identity verification requirements.

North Carolina Office of Vital Records has a 100% identity verification policy. Proof of the requestor's identity

is required no matter which ordering method is selected. Requestor must meet our identity and entitlement

verification requirements in order to receive a certificate.

If the name on the identification does not match the name on the certificate, the applicant must provide evidence

of a legal name change. This may include a certified marriage certificate, certified divorce decree or a certified

legal name change court order that reflects the history of the changes to the name(s) on the certificate(s)

requested.

The address on your vital records application must match the address on the applicable identity documents you

provide.

Note: If you are requesting to correct the sex designation on your birth certificate, the sex designations between

the document you present for identity verification here and the sex as it is to be corrected on the birth certificate

are not required to be the same. Please see pages 4-7 for documentation required to support requests to modify

fields on a birth certificate.

Applications that do not include a legible photocopy of one of the IDs

listed below with your request will be denied:

(Form DHHS 1578 - N.C. Vital Records 07/2022)

Proof of Legal Entitlement to Modify a Birth Record Requirements

• If applicants cannot supply the required form(s) of evidence or

identity, they must obtain a court order to support the request

for modification.

• If the registrant (or child named on the certificate) is under the age

of 18, the parent(s) listed on the certificate may request to modify

the certificate. Alternatively, the legal guardian may request to

modify and must supply an original copy of the guardianship order.

o If the request is to modify the registrant's name or sex

designation, both parents or guardians listed on the

certificate or legal guardian must sign the modification

application, provided they each have the necessary legal

authority, including as determined by a court (such as

through an adjudication of legal custody or abandonment)

• If the registrant is 18 years of age or older, they may request to

modify the certificate or authorize an agent to modify the certificate

through a notarized power of attorney. The named agent must

supply an original copy of the power of attorney document.

• If the registrant is 18 years of age or older and requires that a

name be added to their certificate when no given name has been

recorded, only the registrant, the parent(s) listed on the certificate

or the legal guardian may request to add the name. The registrant

may not authorize an agent via a power of attorney to perform this

type of modification.

(Form DHHS 1578 - N.C. Vital Records 07/2022)

Documentary Evidence Required to Modify a Birth Certificate

(Form DHHS 1578 - N.C. Vital Records 07/2022)

Documentary Evidence Required to Modify a Birth Certificate

(Form DHHS 1578 - N.C. Vital Records 07/2022)

Documentary Evidence Required to Modify a Birth Certificate

(Form DHHS 1578 - N.C. Vital Records 07/2022)

Documentary Evidence Required to Modify a Birth Certificate

(Form DHHS 1578 - N.C. Vital Records 07/2022)

Documentary Evidence Required to Modify a Birth Certificate

(Form DHHS 1578 - N.C. Vital Records 07/2022)