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AFFIDAVIT FOR CORRECTION 2 o Q Q 0-7-3 673 USE BELOW FOR REQUESTING OFFICIAL CHANGES ONLY ANY CHANGES MADE BELOW VOID THIS CERTIFICATE, A NEW CERTIFICATE MUST BE ISSUED TO VALIDATE CHANGES. NUMBER OF CERTIFICATES FEE NUMBER INITIALS DATE AFFIDAVIT NUMBER STATE OFFICE USE ONLY STATE OFFICE USE ONLY Birth ❑ Marriage ❑ The record of Death ❑ Dissolution ❑ with 1. STATE FILE NUMBER for 2. NAME 3. DATE OF EVENT 4. PLACE OF EVENT (City and County) 5. FATHER'S FULL NAME (If Birth), HUSBAND (If Marriage /D(ssolution) 6. MOTHER'S FULL MAIDEN NAME (If Birth), WIFE (If Marriage /Dissolution) THE RECORD IS INCORRECT OR INCOMPLETE AS FOLLOWS: THE RECORD NOW SHOWS: THE TRUE FACT IS: 7. 8. 9. 10. 11. 12. 13 14. 1 REPRESENT THE PERSON AS (E.G. SELF, PARENT, GUARDIAN, ETC.) SPECIFY 15. I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FORGOING IS TRUE AND CORRECT. All vital recoidv are registered as received. Changes must be made by affidavit. An item may be changed by affidavit only once. Subsequent changes must be made by court order. This certificate must be returned within one year of the date it was issued to receive a replacement copy free of charge. Birth Certificates 1. All changes must be established by documentary proof submitted with the affidavit. 1 Only a parent, Icgal guardian (il'the child is under 18), or the adult themselves (if 1.8 or older) may change the birth certificate. 3. The prool(s) must match exactly the asserted true fact(s). For example, if the affidavit says the name is Mary Ann Doe, then the proof must show the name to be Mary Ann Doe. Mary A. Doe or M.A. Doe does not prove the name is Mary Ann Doe. 4. Proot must be five (or more) years old or established within five years of birth. 5. Lxainples of documents of proof: Certificate of Naturalization Marriage Record School Record Census Record Medical Record Voter's Registration Card (i1 it bears an effective date) Hospital Records Military Record (DD -214) Alien Registration Card (front and back) Insurance Records Your Child's Birth Record Passport 6. Up to age one, the parent(s) or legal guardian may change the child's surname with an affidavit for correction provided: This is a one time only change. Subsequent changes will require a certified copy of a court ordered name change. The new surname may be the mother's maiden name or father's surname (if present on the certificate) or a combination of two. - After age one, surname changes require a certified copy of a court ordered name change. Minor spelling changes may he made with an affidavit and documentary proof. 7. Parent(s) may change their child's first or middle name by completing and signing an affidavit for correction (until their child's 18th birthday). 8. This affidavit cannot be used to add a father to a birth certificate. (use the paternity affidavit - form DOH 110-001 ) Death Certificates I. Only the in onnanl, the fwtual director_ or c,: :utnrs/ad„iinistrators (if evidence confirming such position is prcretited) Wray cirange the non - medical information. 2. The medical information (cause of death) may be changed only by the attending physician or the coroner /medical examiner. Marriage /Dissolution (Divorce) Certificates I. Personal fact (minor spelling changes in name, date or place of birth or residence) may he changed by affidavit plus proof by the person. See description of proofs in births above. A person's Own birth certificate is also acceptable proof. �. To change the date or place of marriage or dissolution, the ufficiant ( marriage) or clerk of court (dissolution) must sign the affidavit. Please send the prookf ) and this form /certificate to: I Attn: Corrections Center for Health Statistics 1 1 12 Quince Street South P.O. Box 9709 Olympia, WA 98507 -9709 This is a legal document. Complete in ink and do not alter.