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Office!of!Vital!Records!&!Statistics!
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AFFIDAVIT!TO!AMEND!MISSISSIPPI!CERTIFICATE!OF!LIVE!BIRTH!
(Read!instr uc tion !on !n ex t!p ag e!b e for e!c ompleting!this!form)!
FULL!NAME!AT!BIRTH:!
DATE!OF!BIRTH:!
COUNTY!OF!BIRTH:!
Item!To !B e !C o r re c te d !
Incorre c t!In fo r mation!
Correct!Information!
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Name!of!Signatory:!
Signature:!
_________________________________________!
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Sworn!to!and!subscribed!before!me!this!the!
______!day!____________________,!20________!
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Signature!of!Notary:!
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_________________________________________!
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My!Commission!Expires:_____________________!
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