Form Vs-166 - Application For A New Birth Certificate Based On Parentage
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2APPLICATION FOR A NEW BIRTH CERTIFICATE BASED ON PARENTAGE
This form is used to ADD, REMOVE, or REPLACE information regarding the father and/or mother listed on the
original birth certificate according to an establishment of PATERNITY or a COURT ORDER.
Child’s original birth information:
Type or Print in Blue/Black Ink
Texas
__________________________________________________
Date of Birth:____________/__________/____________ Place of Birth:____________________________________________,
Full name of child as registered at birth
month
day
year
city
Father’s name
Mother’s full maiden name
:________________________________________________________________
:________________________________________________________________________________
We/I hereby request a new birth certificate be filed as evidenced by:
ONE
PLEASE CHECK
OF THE FOLLOWING:
Attached certified copy of court decree (must send all pages of the court order) OR
Acknowledgment of Paternity (Date form was faxed to Vital Statistics or signed before a certified entity: _________________) OR
Attached certified copy of the BIOLOGICAL parents’ marriage license
INFORMATION TO BE PLACED ON NEW BIRTH CERTIFICATE:
:____________________________/_____________________/________________________________
FULL NEW NAME OF CHILD (may require a court order)
First
Middle
Last
Father’s Name:
_____________________/______________/_____________________ Date of Birth:______/_____/________ Place of Birth:___________________________________
First
Middle
Last
month
day
year
State or Foreign Country
Mother’s Full Maiden Name:
___________________/______________/_________________________ Date of Birth:______/_____/_______Place of Birth:______________________
First
Middle
Maiden
month
day
year
State or Foreign Country
WARNING: The Penalty for knowingly making a false statement in this form can be 2-10 years in prison and a fine of up to $10,000. (Texas Health
and Safety Code, Chapter 195).
___________________________________________________________________________
_____________________________________________________________________________
Signature of FATHER or Legal Guardian swearing to this affidavit
Signature of MOTHER or Legal Guardian swearing to this affidavit
______________________________________________________________________
________________________________________________________________________
Father’s address
city
state
zip code
Mother’s address
city
state
zip code
(_____)_____________________________
(______)__________________________________
Daytime telephone number
Daytime telephone number
Sworn to and subscribed before me, this _________day of ______________________,
Sworn to and subscribed before me, this __________day of ______________________,
20_________.
20___________.
_____________________________________________________________________
_______________________________________________________________________
Signature of Notary Public, County Clerk, or other person
Signature of Notary Public, County Clerk, or other person
authorized to administer oaths
authorized to administer oaths
______________________________________________________________________________________
_________________________________________________________________________________________
Printed name and title
Printed name and title
SEE REVERSE SIDE FOR INSTRUCTIONS
•
The fee for filing a new birth certificate is $25.00 An additional fee of $22.00 must be included for a certified copy of the new birth certificate.
Mail this completed and NOTARIZED application with either the attached evidence (certified copy of court order/ marriage license), or filed an
Acknowledgment of Paternity, and the required fee to:
TEXAS VITAL STATISTICS
PO BOX 12040
AUSTIN TX 78711-2040
VS-166 revised 12/2005
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