Establishing secure connection…Loading editor…Preparing document…

Affidavit of Birth for Out-of-Hospital Birth

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Affidavit of Birth Information for Out-of-Hospital Births

This Affidavit is to be Completed at the Local Health Office

I swear or affirm that the information stated is true and correct to the best of my knowledge and belief. I certify that the child named herein was born alive to the stated mother at the place, date, and time shown on this worksheet.

This worksheet was completed with the understanding that the facts so stated herein afford a full, complete, and truthful representation of facts and what my testimony shall be should I be asked or directed to testify to the facts herein in a court of law. I realize that any false statement of facts or information made herein could subject me to the risk of criminal liability, including, but not limited to, prosecution for perjury.

Parent Verification Printed Name
 Written Signature
Relationship to Child
 Date Signed
 Phone Number
Witness Verification Printed Name
 Written Signature
Address – Street Name and Number
 County
City
 State
 Zip
Relationship to Child
 Date Signed
 Phone Number
Attendant Verification

(Physician, Certified Nurse-Midwife, or Licensed Midwife)		 Printed Name
 Written Signature
Address – Street Name and Number
 County
City
 State
 Zip
State License Number
 Date Signed
 Phone Number
Local Registration District Staff Verification Printed Name
 Written Signature
Date Signed

Privacy Notification

The information entered on the worksheet will be transferred to the Certificate of Live Birth (VS 10D) and will be collected by the State of California, Department of Public Health, Office of Vital Records, 1501 Capitol Avenue, M.S. 5103, P.O. Box 997410, Sacramento, CA 95899-7410, telephone number (916) 445-2684. This information is required by Division 102 of the Health and Safety Code. Every element on the worksheet is mandatory, except the items between the double bold lines on the first page of the worksheet. Failure to comply by every person, except a parent informant, is a misdemeanor. The Certificate of Live Birth is open to public access except where prohibited by statute. The principal purposes of this record are to: 1) Establish a legal record of each vital event, 2) Provide certified copies for personal use, 3) Furnish information for demographic and epidemiological studies, and 4) Supply data to the National Center for Health Statistics for federal reports. The father’s and the mother’s Social Security numbers are included pursuant to Section 102425 (b) (14) of the Health and Safety Code, and may be used for child support enforcement purposes.

March 3, 2008

Enter text✕
Prepare your document for signing right on this page
  • 01 Edit the text and complete the fields
  • 02 Click Sign Now and on the next screen add recipients and signature fields in SignNow
  • 03 Start your free trial to sign and send your doc
Sign Now

What the Affidavit of Birth for Out-of-Hospital Birth Is

An Affidavit of Birth for Out-of-Hospital Birth is a sworn statement used to record facts about a birth that occurred outside a licensed hospital setting. The declarant—typically a parent or attending birth attendant—provides details such as the child’s full name, date and time of birth, location, parent names, and the circumstances of delivery. States use this affidavit to issue or amend a birth certificate, establish legal parentage for benefits and identity documents, and create an official contemporaneous record when hospital documentation is absent.

Why this affidavit matters for legal identity and records

The affidavit provides a formal, notarized account that supports issuance or correction of a birth certificate, enables Social Security and health insurance enrollment, and documents legal parentage when hospital records are not available.

Why this affidavit matters for legal identity and records

Who typically completes and relies on this affidavit

The affidavit is most often prepared by the parent, birth attendant, or midwife and submitted to the state vital records office to obtain a birth certificate.

  • Parents or legal guardians preparing documentation for a newborn born at home or another nonhospital setting.
  • Licensed midwives or birth attendants who witnessed or assisted the delivery and attest to birth details.
  • Local vital records staff and social services personnel who verify facts to issue identity documents.

Timely, accurate completion by the appropriate declarant reduces processing delays and supports access to government benefits and identity documents.

Typical signers and their roles

Parent / Declarant

A parent or legal guardian signs to attest to the child’s identifying details and circumstances of birth; the statement is a sworn declaration and may be notarized or witnessed to meet state filing requirements.

Attendant / Midwife

The attending midwife or birth attendant provides an attestation of observations (time, place, condition) and may co-sign, offering corroboration needed by vital records offices for nonhospital deliveries.

Key data fields included in the affidavit

Child Name: Full legal name
Date of Birth: MM/DD/YYYY format
Birth Location: Street, city, state
Parent Names: Full legal names
Attendant Statement: Witnessing details
Notary Block: Signature, date, seal

Consequences of errors or omissions

Delayed Birth Certificate: Processing delays
Benefits Denial: Social Security or insurance impact
Legal Challenge: Parentage disputes
Incorrect Records: Identity document mismatches
Perjury Exposure: False statements risk legal penalties
Administrative Fees: Additional filing or amendment costs

Common preparation problems to avoid

  • Incomplete details such as missing middle names or an imprecise birth location can trigger requests for supplemental proof and prolong issuance of a birth certificate.
  • Mismatched or abbreviated parent names that do not match government IDs often require notarized affidavits or additional identity documents to resolve.
  • Unsigned or undated affidavits, or affidavits lacking required witness or notary acknowledgements, are frequently rejected by state vital records offices.
  • Failing to include the attending professional’s contact information or license number (when required) can undermine the affidavit's weight and result in further verification requests.

Step-by-step: completing the affidavit

Follow these sequential steps to assemble, complete, and file an Affidavit of Birth for Out-of-Hospital Birth.

  • 01
    Gather documents: Collect IDs, proof of residence, and any attendant notes.
  • 02
    Complete form: Enter full names, DOB (MM/DD/YYYY), and precise location.
  • 03
    Authenticate: Sign before a notary or required witness per state rules.
  • 04
    File: Submit to county or state vital records office.

Where you submit the affidavit and how it moves

Affidavits typically flow from declarant to local vital records and then to state-level registries for certificate issuance; processing depends on jurisdictional procedures.

  • County Vital Records: Initial filing point in many jurisdictions
  • State Vital Records: Final review and birth certificate issuance
  • Social Security Office: Used to enroll newborns for SSN issuance
  • Health Insurance: Supports newborn enrollment and coverage

Configuring an online completion workflow

Set up the digital workflow to collect verified inputs, optional attachments, and required authentications before filing.

Document Type PDF form with fillable fields
Authentication Email or SMS code for signer verification
Attachments Upload IDs, attendant notes, and proof
Notary Option Enable remote online notarization when available
Routing Order: declarant → attendant → notary → records

Digital signing and file-format considerations

Use platforms that accept PDF and DOCX, capture an audit trail, and support notarization workflows where required.

  • Supported Formats: PDF, DOCX, fillable forms
  • Authentication Options: Email, SMS, KBA, or 2FA
  • Integrations: CRM and cloud storage connectors

Ensure the chosen platform can produce a tamper-evident signed PDF, capture signer attribution, and retain records in line with legal retention obligations.

Essential sections of a professional affidavit

A complete affidavit follows a predictable structure so vital records staff can verify and accept the document without additional back-and-forth.

Header

Document title, jurisdiction, and statement that this is an Affidavit of Birth for Out-of-Hospital Birth; identifies the governing state and the purpose of the affidavit to support birth registration.

Child Details

Full legal name, sex, date and time of birth (enter as MM/DD/YYYY and local time), and birthplace with street address, city, county, and state to match jurisdictional reporting requirements.

Parent Information

Full legal names, dates of birth, and mailing addresses for mother and father or legal guardians; include contact telephone and email for verification by vital records staff when permitted.

Attendant Narrative

Attending midwife or person present recounts circumstances of delivery, condition of child at birth, and any medical observations needed to corroborate the event for issuance of a certificate.

Oath and Signature

Declarant signs under oath; the affidavit includes a notary or witness block with signature, printed name, title, date, and official seal where state law requires authentication.

Filing Instructions

A short block indicating where to submit the completed affidavit, required attachments (IDs, attendant statement), and any local fees or processing notes to help the applicant complete filing correctly.

eSignature pricing snapshot for affidavit workflows

Annualized starting prices and basic capability signals to consider for eSignature providers used to collect and notarize affidavit signatures.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies Varies Varies Varies
Bulk Send Yes Yes Yes Yes Yes
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/year Varies by plan Varies by plan Varies by plan

Frequently asked questions and practical answers

Answers to common questions about acceptability, notarization, corrections, and electronic signing for Affidavits of Birth for Out-of-Hospital Birth.


Need help? Contact support

Explore Templates

Idaho Pre Incorporation Agreement Single Member Managed LLC Operating Agreement Small Claim Form 3rd Judicial District Idaho Affidavit of Competence Small Claim Form SC-3 1 3rd Judicial District Idaho Idaho Small Claims Form
be ready to get more
Join over 28 million airSlate SignNow users
Sign Now
Company
Forms
Pricing
Resources
Knowledge base
Other Products
© 2026 airSlate Inc. All rights reserved.