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NYC Birth Certificate Correction Checklist

To change the name & gender on a birth certificate issued by New York City, assemble the following. Corrections take 6-8 weeks.

* One certified copy of the name change order. They will send it back.

* One photocopy of the name change order. DO NOT REMOVE ANY RECEIPT OR STAPLES when copying the order. Alternatively, you can print out a scan of the final order.

* One original affidavit/affirmation from a health care provider. (There is a specific form provided by NYC. The provider should use the name that is on the birth certificate.) They will send it back.

* One photocopy of the health care provider affidavit/affirmation.

* Birth Certificate Correction Application (NYC Form VR-172).

o In Section 1, fill in your name (or the parent’s name if the person is under 18). In Section 2, put the old name & sex.

o In Section 3, under “items to be corrected” list “child’s sex” and then male/female as appropriate. List separate lines for each name that you are correcting, for example “child’s first name” “child’s middle name” and fill in the information accordingly.

o Leave Section 4 blank. Sign in Section 5 on the second page (or if under 18, both parents listed on the birth certificate must sign)

* A photocopy of the front & back of your current, signed photo identification, or if under 18, for both parents who signed.

* A check or money order for $55 made out to the NYC Dep’t of Health and Mental Hygiene ($40 processing fee + $15 for a copy). Order only one corrected copy with this application and order more later if desired.

* A self-addressed, stamped envelope.

Mail your documents to:

NYC Department of Health and Mental Hygiene Corrections Unit 125 Worth Street, Room 144, CN-4 New York, NY 10013

Questions? Email tgnyc@health.nyc.gov or call 311.

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NYC Birth Certificate Correction: Provider Instructions

ü On the form below, use the patient’s name as it appears on their birth certificate;

ü Fill in all blank lines;

ü If you are not a physician, you must have this form notarized;

ü Mail the original, signed document to the patient. Electronic copies are not accepted.

Questions? Email info@transcendlegal.org or call (347) 612-4312.

January 14, 2015

Provider’s letterhead OR Patient’s Full Name Provider’s address: _______________________ Provider’s phone: ______________ Provider’s email: __________________

Patient’s/Client’s Full Name: __________________

Patient’s/Client’s Date of Birth: _______________

Patient’s/Client’s Address: ___________________

I, __________________________________, am a U.S.-licensed healthcare provider in good standing: (Provider’s full name) Please check one box:

Physician (MD or DO)

Doctoral-level psychologist (PhD or PsyD in clinical or counseling)*

Social worker (LMSW or LCSW)*

Physician assistant*

Nurse practitioner*

Marriage and family therapist*

Mental health counselor*

Midwife*

I am the healthcare provider of ___________________, whom I have treated (or whose history I have (Name of patient/client)

reviewed and evaluated). I hereby certify and confirm that, in keeping with contemporary expert standards regarding gender identity, _______________‘s requested change of sex designation from ______ to ______ accurately (Name of patient/client) (M/F) (M/F) reflects their gender identity.

I declare under penalty of perjury under the laws of the United States that the forgoing is true and correct. Signature of Provider: ___________________________________________________________________ Typed or Printed Name of Provider: _______________________________________________________ Date: ________________________________________________________________________________ License Number: ___________________________________ State Issued: ___________________ License Type: __________________________________________________________________________ NPI Number: __________________________________________________________________________

Provide notary’s signature and legal information in box below:

Note: Notarization of this

letter is required for providers

with an asterisk (*).

List items to be corrected

Please use one line per correction. We cannot accept white-outs or cross-outs; if you make a mistake, please use a new application form.

Write errors as they appear on birth record What should it say on birth record?

Example: Child’s First Name

Example: Date of Birth

Not Shown

October 16, 2009

Michael

October 19, 2009

DEPARTMENT OF HEALTH AND MENTAL HYGIENE • OFFICE OF VITAL RECORDS

Birth Certificate Correction Application Form

Reference No.

VR 172 (Rev. 01/15)

Please use blue or black ink ONLY.

–TelephoneNumber

WirelessCarrier

Email Address

First Name Middle Name Last Name

Apartment Number

ZIP CodeStateCity

Home

Area Code Telephone Number

–Cell

Area Code Telephone Number

–Daytime

Area Code Telephone Number

Mailing Address

Marital Partnership Status

□ Single □ Divorced

□ Married □ Widowed

□ Separated □ Domestic Partnership

Name on Birth Certificate as it now appears

Birth Certificate Number

Date of BirthSex

First Name Middle Name

Month Day Year

□ Male □ Female

Last Name

Mother’s Maiden Name

First Last

– –

/ /Place of Birth

Name of Hospital, birthing center or if born at home, street address, city, state, ZIP)

Section 1: What Is Your Name? You Must Be At Least 18 Years Old

Section 2: Birth Certificate Information

Section 3: What Do You Want To Correct?

1 5 6

□ AT & T □ T-Mobile □ Sprint □ Verizon

□ Other _______________________________________

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This is to certify that I have examined the original record that this application seeks to correct, and any originaldocuments required to verify the correction. There are no omissions or apparent errors in the original record that havenot been covered. Therefore, the application is approved.

Signature of Deputy City Registrar Date

Your Signature (if you are 18 or older and are requesting a correction of your own birth certificate)

Signature of Mother/Parent/Legal Guardian

Signature of Father/Parent/Legal Guardian

Signature of Self

Date

Date

Date

Warning! No person shall make a false, untrue or misleading statement or forge the signature of another on an application required to be prepared pursuant

to the New York City Health Code. A violation of the Health Code shall be punishable as a misdemeanor. (NYC HEALTH CODE 3.19)

DOCUMENT NO.

If you want to add the name of another parent, please fill out this section. You must have been married prior to the birth ofthe child. See “How Do I Add the Name of Another Parent?” on page 2.

Please sign the form where appropriate. If both parents’ names appear on the birth certificate, both must sign if the child is under 18.

Second Parent’s

Date of Birth

Second Parent’s Age

at Time of Child’s Birth

Sex

Month Day Year

□ Male □ Female / /

First Name Middle Name Last Name of Second Parent

Child’s Last Name (as it will appear on the certificate even if it will remain the same) Signature of Second Parent Date

Parent’s Country of Birth

How to Submit Your Application:

A copy of the corrected certificate costs $15. This fee is waived if you enclose a certified copy of a certificate purchasedwithin the past 3 months and want to exchange it for a corrected certificate.

Figure out the cost: Processing Fee: $40 (See page 1 for applicable fees. $ _________( not all corrections have a fee.)

Copy Fee: number of copies _________ X $15 each $ _________

Total Amount Enclosed: $ _________

Please make your check or money order payable to the: New York City Department of Health and Mental Hygiene.Cash not accepted. Walk-in customers may pay using a credit or debit card.

Make certain you have enclosed everything necessary (please check all that apply):□ Completed, signed application with a copy of photo □ One photocopy of each original or certified copy

identification for each parent named on birth record □ Payment if applicable □ Original or certified documents □ If mailing, self-addressed, stamped envelope.

Submitting false identification is a crime and violators are subject to prosecution.

MAIL TO: NYC Department of Health and Mental HygieneCorrections Unit125 Worth Street, Room 144, CN-4New York, NY 10013

VR 172 (Rev. 01/15)

Section 4: Second Parent Information

Section 5: Sign Your Application

Certification by the NYC Department of Health and Mental Hygiene

Name of Second Parent

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FOR HEALTH DEPARTMENT USE ONLY