Pennsylvania Department of Health - Vital Records · Pennsylvania state form
Name Redaction Request Form HD02046F
This form lets a birth parent request redaction of their name from an adopted person’s noncertified original birth record, or withdraw a prior redaction request.
- What this form is
- A birth parent can use this form to request that their name be redacted from documents issued against an adopted person’s original birth record, or to remove a previously filed redaction request. The form asks for information about the birth parent and the original birth record. Include two forms of identification. The birth parent must sign the form before a notary.
- Who needs it
- A birth parent listed on an original birth record who wants to request or withdraw a name redaction.
- Why it needs a notary
- The birth parent’s signature must be notarized. You can complete this step online with a commissioned online notary.
- How to submit it
- Mail the completed form and two forms of identification to the Department of Health, Bureau of Health Statistics & Registries, Birth Registry, 555 Walnut Street, 6th Floor, Harrisburg, PA 17101-1934.
Questions
Who can submit the Name Redaction Request Form?
A birth parent listed on an adopted person’s original birth record may complete the form to request that their name be redacted from documents issued against that record.
Does this form need to be notarized?
Yes. The form includes a subscribed-and-sworn or affirmed section and a notary signature line. A commissioned online notary can notarize the signature online.
What must I send with the form?
Send two forms of identification with the completed request. The form lists examples, including a valid government-issued photo ID verifying your name and current mailing address.