Affidavit for Correction Mail to: Center for Health Statistics

P.O. Box 47814

Olympia, WA 98504-7814
This is a legal document. Complete in ink and do not alter. 360-236-4300
DOH 422-034 August 2019
STATE OFFICE USE ONLY
State File Number Fee Number Initials Date Affidavit Number

Required information must match current information on record

Record Type: Birth Death Marriage Dissolution (Divorce)
Required

1. Name on Record: 2. Date of Event: 3. Place of Event:

First Middle Last MM/DD/YYYY (City or County)
4. Father/Parent Full Birth Name (Spouse A for Marriage or Dissolution) 5. Mother/Parent Full Birth Name (Spouse B for Marriage or Dissolution)
First Middle Last/Maiden First Middle Last/Maiden
6. Name of Person Requesting Correction: Relationship to Self Guardian Informant Hospital
Person on Record: Parent(s) Funeral Director Other (specify)___________________

7. Return Mailing Address:

PO Box or Street Address City State Zip
Telephone Number: Email Address:
( )
Use the section below for requesting any changes on the record. The record is incorrect or incomplete as follows:
The record currently shows: The true fact is:
8. 9.
10. 11.
12. 13.

I declare under penalty of perjury under the laws of the State of Washington that the forgoing is true and correct.
14a. Signature: 14b. Signature of 2nd parent (if required):

Printed name: Date: Printed name: Date:

INSTRUCTIONS – go to www.doh.wa.gov for more information

Required proof documentation must be submitted with the affidavit and include full name and birth date. Examples of proof documentation include:
 Birth/Marriage/Divorce record  Military record (DD-214)  School transcripts  Social Security Numident Report
 Certificate of Naturalization  Hospital/medical record  Copy of Passport / Enhanced ID  Green/Permanent Resident card (I-551)
You cannot use a Driver’s license, Social Security card, or hospital decorative birth certificate as proof documentation.
Birth Certificates
1. Only a parent(s), legal guardian (if the child is under 18), or the named individual (if 18 or older) may change the birth certificate.
2. The proof(s) must match the asserted fact(s). For example, if the affidavit says the name should be Mary Ann Doe, the proof must show the name to be Mary
Ann Doe.
3. Proof documentation must be five or more years old or established within five years of birth.
4. This affidavit cannot be used to add a parent to a birth certificate (use Acknowledgment of Parentage form DOH 422-159).
Child under 18 Adult (18 years or older)
 If legal guardian(s), include certified court order proving guardianship.  Only the adult can change their own birth certificate.
 Up to age one or up to one year following the filing of an Acknowledgement  If the first or middle name is missing, three pieces of proof documentation are
of Parentage form, last name can be changed once to either parents’ name required.
on certificate (can be any combination of the first, middle or last names);  If the first, middle and/or last name is misspelled, or month and/or day of birth
thereafter, a court order is required to change the last name. is incorrect, two pieces of proof documentation are required.
 No proof is required to change the first or middle name.*  To correct parent’s birth date, place of birth, or name, one proof documentation
 To correct parent’s information, one proof documentation is required. is required.
 To correct the sex of the child, one proof documentation from a medical
provider is required.
*To change any part of the name of a child using this form, signatures from both parents listed on the certificate are required. If one parent is deceased, submit a death
certificate with request.
Death Certificates
1. Only the informant may change the non-medical information without proof documentation. The funeral director, executors/administrators, or a family member
may change the non-medical information with proof documentation. Family members are spouse or registered domestic partner, parent, sibling, or adult child
or stepchild. Marital status requires a certified court order if someone other than the informant is requesting the change.
2. The medical information (cause of death) may be changed only by the certifying physician or the coroner/medical examiner.

Marriage/Dissolution (Divorce) Certificates

1. Personal facts (minor spelling changes in name, date or place of birth, or residence) may be changed by the person with one piece of proof documentation.
2. To change the date or place of marriage or dissolution, the officiant (marriage) or clerk of court (dissolution) must complete and submit the affidavit.