STATE OF NEVADA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Division of Public and Behavioral Health
Preparedness, Assurance, Inspections and Statistics
Office of Vital Records and Statistics
4150 Technology Way, Suite 104
Carson City, Nevada 89706
Telephone: (775) 684-4242 · Fax: (775) 684-4156
BIRTH
DEATH
AFFIDAVIT FOR CORRECTIONS OF A RECORD
State Affidavit No.____________
PLEASE READ THE INSTRUCTIONS ON THE BACK OF THIS FORM
INFORMATION
AS REPORTED
ON THE
ORIGINALLY
REGISTERED
CERTIFICATE
1a. FIRST NAME
1b. MIDDLE NAME
1c. LAST NAME
2. SEX
3. DATE OF BIRTH / DEATH
4. PLACE OF OCCURRENCE (City or County)
5. NAME OF FATHER
STATEMENT
OF
CORRECTIONS
7.
ITEM
NUMBER
8a.
FACTS EXACTLY AS STATED ON THE ORIGINAL RECORD
8b.
FACTS AS THEY SHOULD HAVE BEEN STATED ON THE ORIGINAL AT THE TIME OF OCCURRENCE
WHY ARE
CORRECTIONS
NECESSARY?
9.
I, ___________________________________, currently residing at ___________________________________________________________,
(Print Full Legal Name) (Print Street, City, State, Zip Code)
in relation to the person of record being amended, _____________________, certify and declare under penalty of perjury under the laws of
(Print Relationship)
the State of Nevada, that all assertions of this affidavit are true and accurate to the best of my knowledge.
Witness Signature: ___________________________________________
(Sign in the Presence of a Notary)
_______________________________________________________________________________________________________________________________________________________________________________________________
State of _________________,
County of ________________,
Signed and sworn (or affirmed) before me on this ______day of _____________________, 20________,
by ___________________________________________.
(Name of Person Making the Statement)
The subscribing affiant appeared before me, and proved on the basis of satisfactory evidence, to be the person whose name is within instrument
and affirmed to me. Affiant executed the same in their authorized capacity, and that by the affiant’s signature on the instrument, the person,
or the entity upon behalf of which the person acted, executed the instrument. I certify under penalty of perjury under the laws of the State of
Nevada that the foregoing paragraph is true and correct.
Notary Public: __________________________________ WITNESS my hand and official seal.
My Commission Expires: _________________________
_________________________________________
(Signature of Notary Public)
Reserved for Notary Seal
INSTRUCTIONS
Who can submit an Affidavit for Correction of a Record?
To correct a BIRTH CERTIFICATE, the witness signing this affidavit must have a relationship with the person of record as
the person whose birth is registered on the certificate, his/her parent, guardian, or a legal representative. Medical
information must be by the certifier.
To correct a DEATH CERTIFICATE, the witness signing this affidavit must have a relationship with the person of record as
the funeral director, certifier or informant listed on the certificate. Medical information must be by the certifier.
What do I need to submit with the Affidavit for Correction of a Record?
A supplemental affidavit executed by a person other than the affiant of this Affidavit for Correction of a Record OR
other verifiable evidence corroborating the facts contained in the principal affidavit.
The payment of $40.00 (includes one certified copy of the corrected certificate). Additional certified copies of a birth
certificate or death certificate is $20.00 each. The payment may be made by check, cashier’s check, money order or credit
card. Please make your check, cashier’s check or money order out to the Nevada Office of Vital Records. To pay by credit
card, an Authorization for Credit Cards Use form must be completed and submitted.
PLEASE NOTE: The fee for correcting a birth or death record where the correction is filed by a certifier and the State Registrar
determines that the correction is not the result of an error by the certifier is $10.00.
How do I properly complete the Affidavit for Correction of a Record?
This is a legal document. Please type or print clearly in blue or black ink only. Illegible completion of the form will be
returned. Any white outs, cross outs or write overs will not be accepted. The Affidavit for Correction of a Record must be
fully completed in order to be processed.
Signature of the witness must be notarized. Signatures of a minor will be questioned. The person should be at least
18 years of age to make a correction.
Please complete the section titled “Statement of Corrections” clearly and accurately.
Where do I send the Affidavit for Correction of a Record and supporting documents?
Division of Public and Behavioral Health
Office of Vital Records and Statistics
4150 Technology Way, Suite 104
Carson City, Nevada 89706
Please allow 2 – 4 weeks to process your request. Any questions regarding correcting a record should be addressed to the
Office of Vital Records at the above address, or by calling our office at 775-684-4242. Please provide the name, full
address of where the certificate should be mailed to and phone number:
..........................................................................................................................................................................................................................................
Name
..........................................................................................................................................................................................................................................
Street Address or P.O. Box
..........................................................................................................................................................................................................................................
City
State
Zip Code
..........................................................................................................................................................................................................................................
Phone Number