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)
____________________________________