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AFFIDAVIT TO CORRECT BIRTH CERTIFICATE

STATE OF

COUNTY OF

INFORMATION AS IT APPEARS ON THE ORIGINAL BIRTH CERTIFICATE:

Name as Recorded

Date of Birth

Place of Birth

Father's Name

Mother's Maiden Name

ITEMS TO BE CORRECTED OR ADDED

SHOULD READ

THE FOLLOWING AFFIDAVIT IS TO BE COMPLETED BY THE PERSON WHOSE BIRTH CERTIFICATE IS TO BE CORRECTED:

I, , born and residing at

being first duly sworn, say that to

the best of my knowledge and belief the foregoing facts are true and correct.

SIGNATURE

DATE SIGNED

SIGNATURE OF NOTARY PUBLIC

COMMISSION EXPIRES SEAL:

MAIL TO: VITAL REGISTRATION
                  ATTN: CORRECTION UNIT
                  P.O. BOX 11012
                  CHARLESTON, WV 25339-1012
                  (304) 558-2931