REQUEST TO CHANGE BIRTH CERTIFICATE

							                                                                                                          Print Form


           REQUEST TO CHANGE A CHILD’S BIRTH CERTIFICATE BASED
           ON COURT ORDER OF NAME CHANGE FOR PARENT OF CHILD

   I hereby request the Center for Health Statistics to change a child’s surname and the
   parent’s name on the Oregon birth certificate as stated in the court ordered decree of
                                name change for a parent:

Child’s Name Now on Birth Certificate:

   First ____________________ Middle ______________________Last _____________________________

   Child’s date of birth: _________________       Child’s Place of Birth: ________________________________

New Surname of Child Based on Parent’s Court Order of Name Change:

   Last _____________________________

Parent’s Name Now on Birth Certificate:

First ____________________ Middle ______________________Last _____________________________
                                                                                  (Maiden)
 Parent’s New Name as it is to appear on Birth Certificate

 First ____________________ Middle ______________________Last _____________________________
                                                                                         (Maiden)
 Please indicate which items should be changed on the birth certificate:

 Parents’ legal last name: _____    Mother’s Maiden Name: _____       Both Legal & Maiden Name: _____

 Informant’s Name: _____


____________________________________________________                              ____________________
Signature of person on birth certificate or parent if under age 18                       Date signed

____________________________________________________                 ___________________________________
Print Name                                                                 Daytime Telephone Number

____________________________________________________
Relationship to person on birth certificate


This signed form and a certified copy of the court order showing the original seal and signature of the court
clerk (our office will keep this document in a sealed file) must be returned with appropriate fee to:
                                                Amendment Clerk
                                          Center for Health Statistics
                                                  PO Box 14050
                                           Portland, OR 97293-0500                                    Rev 1/2010