California Department of Public Health - Vital Records · California state form

VS 107 Supplemental Name Report – Birth

Use the VS 107 to add a child’s name to blank fields on a birth certificate. The form is submitted to California Vital Records for an amendment.

What this form is

The VS 107 Supplemental Name Report – Birth is used to add a child’s name to blank fields on the child’s birth certificate. Complete the form in black ink, with Part I matching the current certificate. Two people with knowledge of the facts must complete Part II, and at least one must be a parent. A notarized sworn statement is required only when requesting an authorized copy.

Who needs it

A person requesting to add a child’s name to blank fields on the child’s birth certificate may use this form to request an amendment.

Why it needs a notary

A notarized sworn statement is required when requesting an authorized copy. The applicant’s signature must be notarized; this can be done online with a commissioned online notary.

How to submit it

Mail the completed VS 107 and applicable payment to California Department of Public Health, Vital Records – Amendments – M.S. 5105, P.O. Box 997410, Sacramento, CA 95899-7410. Include a notarized sworn statement only if requesting an authorized copy.