Fill and Sign the Birth Certificate Modification Package Mississippi Form

Prepared by U.S. Legal Forms, Inc. Copyright 2016 - U.S. Legal Forms, Inc. STATE OF MISSISSIPPI MODIFICATION OF MISSISSIPPI BIRTH CERTIFICATE Control Number – MS – 61119 This packet contains the following: 1. Instructions ; 2. Forms ; and - 1 - NOTE ABOUT COMPLETING THE FORMS The forms in this packet contain “form feldss created using Microsoft Word. “Form feldss facilitate completion of the forms using your computer. They do not limit you ability to print the form “in blanks and complete with a typewriter or by hand. If you do not see the gray shaded form felds, go the View menu, click on Toolbars, and then select Forms. This will open the forms toolbar. Look for the button on the forms toolbar that resembles a shaded letter “as. Click in this button and the form felds will be visible. The forms are locked which means that the content of the forms cannot be changed. You can only fll in the information in the felds. If you need to make any changes in the body of the form, it is necessary for you “unlocks or “unprotects the form. IF YOU INTEND TO MAKE CHANGES TO THE CONTENT, DO SO BEFORE YOU BEGIN TO FILL IN THE FIELDS. IF YOU UNLOCK THE DOCUMENT AFTER YOU HAVE BEGUN TO COMPLETE THE FIELDS, WHEN YOU RELOCK, ALL INFORMATION YOU ENTERED WILL BE LOST. To unlock click on “Toolss in the Menu bar and then selecting “unprotect documents. You may then be prompted to enter a password. If so, the password is “uslfs. That is uslf in lower case letters without the quotation marks . After you make the changes relock the document before you being to complete the felds. After any required changes and re-protecting the document, click on the frst form feld and enter the required information. You will be able to navigate through the document from form feld to form feld using your tab key. Tab to a form feld and insert your data. If you have any problems, please let us know. - 2 - I. PETITION FOR MODIFICATION OF BIRTH CERTIFICATE A. In Mississippi, an action for a court ordered Modifcation of Birth Certifcate begins with the fling of a Petition in the Chancery court. The Petition must contain certain information. The forms in this packet include the necessary information for a Modifcation of Birth Certifcate in the State of Mississippi. B. You can use this packet if: ► The person seeking the modifcation was born in Mississippi and has a current Mississippi Birth Certifcate and is currently a resident of the county in which the action is to be fled. ► You have proper and reasonable cause for the requested modifcation of the birth certifcate. II. WHAT FORMS ARE INCLUDED A. Summons – this is the document that is issue, or signed by the Clerk of the Chancery in their ofcial role, and served on the respondent that formally notifes them of the pending legal action in which they have been named a party and informs them of their right to respond. It is served on The Bureau of Vital Statistics and any respondent such as an alleged father of the child; an individual it is alleged is wrongfully named on the birth certifcate; etc. B. Petition to Change Name - This document states the reasons and other required details for your name change. C. Notice – form addressed to the Mississippi State Department of Health, Bureau of Vital Records, informing them of their responsibilities regarding a response to the Petition. D. Notice – form addressed to an individual respondent, if any, who is entitled to notice of the lawsuit and who is to be a named Respondent. E. Order/Judgment Authorizing Modifcation of Birth Certifcate – this is the formal court order requiring the modifcations be made by the Respondent Bureau of Vital Records. F. Form letter for ordering a certifed “longs copy of the person’s birth certifcate. Enclose $15.00 money order for fee and the form located at: http://www.msdh.state.ms.us/phs/forms/Form %20522E_201407.pdf. G. Form letter for conveying certifed copy of Court's Order to Bureau of Vital Records and requesting the issuance of a - 3 - modifed birth certifcate as authorized by the Order. Enclose money order in the amount of $15.00. III. PROCEDURE FOR MODIFICATION OF BIRTH CERTIFICATE A. Preliminary Note: 1. The attached forms may be completed by: a. Printing the forms and completing by hand. Use black ink and print neatly. b. Printing the forms and completing using a typewriter. c. By completing the forms on your computer using a word processing program and then printing the forms. 2. Use complete names and not initials. Check your spelling carefully, a misspelled word can delay your name change. 3. Print three (3) complete sets of forms. 4. All forms with a heading – the name of the court, the Petitioner’s name, the case number, and the name of the document – require that the heading be completed. You will need to add the name of the court and the full name of the Petitioner. The “Action/Cause No.s will be assigned by the court clerk at the time of fling. 5. Forms that require your signature and include a notary block MUST be signed in the presence of the notary or court clerk who will complete the acknowledgement. Use your complete name – frst name, middle name, last name. 6. When a form is fled with the court, request the clerk “fle- stamps one copy of the form for your fle. 7. A Law Summary is available and can be printed for your State. To do so, go to the last page of this package and select the Law Summary link under the form title and print. Review the Law Summary before beginning the process of completing the forms. B. Procedure NOTE: If you do not have a certifed “longs form birth certifcate, use the enclosed for letter in ordering one from the Bureau of Vital Records. - 4 - You will have to attach one certifed copy to the Petition at the time of fling. Step 1: Complete all the forms using complete names – middle names instead of middle initials. Step 2: File the Petition in the Chancery Court in the county in which you have been a resident and pay the appropriate fee. Also, submit two copies of the Summons and request the Clerk to issue the summons. Step 3: Mail one “issueds Summons and a copy of the Petition which has been stamped “fleds by the Clerk to the Bureau of Vital Records at the following address: MISSISSIPPI STATE DEPARTMENT OF HEALTH VITAL RECORDS P.O. Box 1700 Jackson, Ms 39215-1700 An uninterested party should then execute the proof of service after personally mailing the Summons and Petition to the Bureau of Vital Records. Step 4: Approximately 30 or 40 days after serving the “Bureau of Vital Recordss, contact the Clerk and ask to schedule a hearing. By this time you should have received a response to the service from the Bureau of Vital Records. Generally, the Bureau of Vital Records will fle their Response to the Petition with 20 days of service. Step 5: Appear as directed by the Clerk and present the Judgment to the Court. The court will place at least one of the Petitioners under oath and take brief testimony concerning the Petition. Step 5: Obtain a certifed copy of the Judgment from the Clerk after it has been signed by the Judge. Step 6: Send certifed copy of the Judgment Authorizing Modifcation of the Birth Certifcate to the Bureau of Vital Records and request issuance of amended Birth Certifcate. - 5 - DISCLAIMER These materials were developed by U.S. Legal Forms, Inc. based upon statutes and forms for the State of Mississippi. All Information and Forms are subject to this Disclaimer: All forms in this package are provided without any warranty, express or implied, as to their legal efect and completeness. Please use at your own risk. If you have a serious legal problem we suggest that you consult an attorney. U.S. Legal Forms, Inc. does not provide legal advice. The products ofered by U.S. Legal Forms (USLF) are not a substitute for the advice of an attorney. THESE MATERIALS ARE PROVIDED "AS IS" WITHOUT ANY EXPRESS OR IMPLIED WARRANTY OF ANY KIND INCLUDING WARRANTIES OF MERCHANTABILITY, NONINFRINGEMENT OF INTELLECTUAL PROPERTY, OR FITNESS FOR ANY PARTICULAR PURPOSE. IN NO EVENT SHALL U. S. LEGAL FORMS, INC. OR ITS AGENTS OR OFFICERS BE LIABLE FOR ANY DAMAGES WHATSOEVER (INCLUDING, WITHOUT LIMITATION DAMAGES FOR LOSS OF PROFITS, BUSINESS INTERRUPTION, LOSS OF INFORMATION) ARISING OUT OF THE USE OF OR INABILITY TO USE THE MATERIALS, EVEN IF U.S. LEGAL FORMS, INC. HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. - 6 - IN THE CHANCERY COURT OF ____________ COUNTY, MISSISSIPPI CAUSE NO. __________________ SUMMONS STATE OF MISSISSIPPI TO:                   NOTICE TO RESPONDENT / DEFENDANT THE COMPLAINT OR PETITION WHICH IS ATTACHED TO THIS SUMMONS IS IMPORTANT AND YOU MUST TAKE IMMEDIATE ACTION TO PROTECT YOUR RIGHTS. You are summoned to appear and defend against said complaint or petition at ____________ a.m./p.m. on the ______ day of ____________ , ______ , before the Honorable ______________________________ at the __________________ County Courthouse at __________________ , Mississippi, and in case of your failure to appear and defend a judgment will be entered against you for the money or other things demanded in the complaint or petition. You are not required to file an answer or other pleading but you may do so if you desire. Issued under my hand and the seal of said Court, this ______ day of ____________ , 20 ______ . (Seal) CHANCERY CLERK ____________ COUNTY, MISSISSIPPI BY: ________________________D.C. Summons Page 1 of 1 IN THE CHANCERY COURT OF __________________ COUNTY STATE OF MISSISSIPPI IN THE MATTER OF             Petitioner(s) AND NO. __________________ MISSISSIPPI STATE BOARD OF HEALTH AND       Respondent(s) PETITION TO CORRECT BIRTH CERTIFICATE Comes now ________________________ , the natural father and ________________________ , the natural mother of the minor herein, and prays this Honorable Court to modify the Certificate of Live Birth so as to make the following modifications: Change the Name of the Father to:       Change the child’s name to:       and in support of this Petition would show unto this Court the following facts, to-wit: I That the Petitioner(s), ______________________________ , is the natural father and ______________________________ is the natural mother of the minor child. II Petitioners, ________________________ and ________________________ , were weren’t legally married on at the time of the birth of       Petition to Correct Birth Certificate Page 1 of 3 . III Following the birth of the minor child, ________________________ , on ________________________ , the child’s name was listed on the Certificate of Live Birth as ____________________________________ . This was an error and the child’s name should have been listed as ____________________________________ because:       WHEREFORE, PREMISES CONSIDERED, Petitioner prays that this Court order the necessary changing of records with the Mississippi State Department of Health, Bureau of Public Health Statistics, Vital Records Division, of the State of Mississippi, to make the following modification in the Birth Certificate of       : Change name from (current full name):       To: (new full name):       Petition to Correct Birth Certificate Page 2 of 3 Date:       Petitioner       Type or Print Name Date:       Petitioner       Type or Print Name STATE OF MISSISSIPPI, COUNTY OF __________________ Personally appeared before me, the undersigned authority in and for the above jurisdiction, ______________________________ who on oath acknowledged that she signed and delivered the above and foregoing Petition To Correct Birth Certificate on the day and year herein mentioned as and for her own act and deed and that the matters of fact therein contained are true and correct as stated. GIVEN UNDER MY HAND AND OFFICIAL SEAL, this the ______ day of ____________ , 20 ______ . (SEAL) Notary Public My Commission expires:       Type or Print Name STATE OF MISSISSIPPI, COUNTY OF __________________ Personally appeared before me, the undersigned authority in and for the above jurisdiction, ______________________________ who on oath acknowledged that she signed and delivered the above and foregoing Petition To Correct Birth Certificate on the day and year herein mentioned as and for her own act and deed and that the matters of fact therein contained are true and correct as stated. GIVEN UNDER MY HAND AND OFFICIAL SEAL, this the ______ day of ____________ , 20 ______ . Petition to Correct Birth Certificate Page 3 of 3 (SEAL) Notary Public My Commission expires:       Type or Print Name Petition to Correct Birth Certificate Page 4 of 3 IN THE CHANCERY COURT OF __________________ COUNTY STATE OF MISSISSIPPI IN THE MATTER OF             Petitioner(s) AND NO. __________________ MISSISSIPPI STATE BOARD OF HEALTH AND       Respondents NOTICE TO:                   The enclosed summons and petition/complaint are served pursuant to Rule 4(c)(3) of the Mississippi Rules of Civil Procedure. You must sign and date the acknowledgment at the bottom of this page. If you are served on behalf of a corporation, unincorporated association (including a partnership), or other entity, you must indicate under your signature your relationship to that entity. If you are served on behalf of another person and you are authorized to receive process, you must indicate under your signature your authority. If you do not complete and return the form to the sender within 20 days of the date of mailing shown below, you ( or the party on whose behalf you are being served) may be required to pay any expenses incurred in serving a summons and petition. If you do complete and return this form, you (or the party on whose behalf you are being served) must respond to the complaint or petition within 30 days of the date of your signature. If you fail to do so, judgment by default will be taken against you for the relief demanded in the complaint or petition. I declare that this Notice and Acknowledgment of Receipt of Summons an Complaint was mailed on ____________ , ______ . Petitioner       Print or Type Name Notice - Individual Page 1 of 2 THIS ACKNOWLEDGMENT OF RECEIPT OF SUMMONS AND COMPLAINT/PETITION MUST BE COMPLETED I acknowledge that I have received a copy of the summons and of the complaint/petition in the above-captioned matter in the State of Mississippi. Date of Signature _____________ Petitioner       Print or Type Name STATE OF MISSISSIPPI, COUNTY OF __________________ Personally appeared before me, the undersigned authority in and for the above jurisdiction, the above named ______________________________ , who on oath acknowledged that the matters and facts set forth in the foregoing ACKNOWLEDGMENT OF RECEIPT OF SUMMONS AND COMPLAINT/PETITION are true and correct as therein stated. Affirmed and subscribed before me this the day of , 1997. (SEAL) Notary Public My Commission expires:       Type or Print Name Notice - Individual Page 2 of 2 IN THE CHANCERY COURT OF __________________ COUNTY STATE OF MISSISSIPPI IN THE MATTER OF             Petitioner(s) AND NO. __________________ MISSISSIPPI STATE BOARD OF HEALTH AND       Respondents NOTICE TO: STATE REGISTRAR OF VITAL RECORDS MISSISSIPPI STATE BOARD OF HEALTH P.O. BOX 1700 JACKSON, MISSISSIPPI 39215 The enclosed summons and petition are served pursuant to Rule 4(c)(3) of the Mississippi Rules of Civil Procedure. You must sign and date the acknowledgment at the bottom of this page. If you are served on behalf of a corporation, unincorporated association (including a partnership), or other entity, you must indicate under your signature your relationship to that entity. If you are served on behalf of another person and you are authorized to receive process, you must indicate under your signature your authority. If you do not complete and return the form to the sender within 20 days of the date of mailing shown below, you ( or the party on whose behalf you are being served) may be required to pay any expenses incurred in serving a summons and petition. If you do complete and return this form, you (or the party on whose behlf you are being served) must respond to the complaint or petition within 30 dys of the date of your signature. If you fail to do so, judgment by default will be taken against you for the relief demanded in the complaint or petition. I declare that this Notice and Acknowledgement of Receipt of Summons and Complaint was mailed on the day of , 1997. Petitioner       Notice – Vital Records Page 1 of 2 Print or Type Name THIS ACKNOWLEDGMENT OF RECEIPT OF SUMMONS AND COMPLAINT/PETITION MUST BE COMPLETED I acknowledge that I have received a copy of the summons and of the complaint/petition in the above-captioned matter in the State of Mississippi. Date of Signature ________________ Signature       Print or Type Name       Office or Title STATE OF MISSISSIPPI, COUNTY OF __________________ Personally appeared before me, the undersigned authority in and for the above jurisdiction, the above named       , who on oath acknowledged that the matters and facts set forth in the foregoing ACKNOWLEDGMENT OF RECEIPT OF SUMMONS AND COMPLAINT/PETITION are true and correct as therein stated. Affirmed and subscribed before me this the day of , 1997. (SEAL) Notary Public My Commission expires:       Type or Print Name Notice – Vital Records Page 2 of 2 IN THE CHANCERY COURT OF __________________ COUNTY STATE OF MISSISSIPPI IN THE MATTER OF             Petitioner(s) AND NO. __________________ MISSISSIPPI STATE BOARD OF HEALTH AND       Respondents JUDGMENT AUTHORIZING MODIFICATION OF BIRTH CERTIFICATE This matter having come on this day to be heard on sworn Petition of       and       , said Petition seeking modification of the original birth certificate of       by the Mississippi State Board of Health and/or Bureau of Vital Statistics of the State of Mississippi to: Change name from (current full name):       To: (new full name):       The Court, having heard the Complaint and the evidence presented in support thereof, is of the opinion and finds as follows: I That this Court has jurisdiction of the subject matter and all necessary parties; II Judgment Page 1 of 2 That this Court finds the facts set forth in the Complaint are true, complete and correct; III That the prayers of the Petitioners should be granted. IT IS, THEREFORE, ORDERED that the Certificate of Live Birth of       be modified so as to change the name: From:       To:       and the Mississippi State Board of Health and/or the Bureau of Vital Statistics of the State of Mississippi be, and they are hereby so authorized to cause to be changed according to the law in the premises the Certificate of Birth (File No. __________________ ), issued __________________ , and relating to ______________________________ . SO ORDERED, this the ______ Day of __________________ , 20 ______ . Chancellor Judgment Page 2 of 2 MISSISSIPPI STATE DEPARTMENT OF HEALTH VITAL RECORDS P.O. Box 1700 Jackson, Ms 39215-1700 Dear Sir or Madam: I have enclosed a money order, in the amount of $ __________________ , payable to Vital Records, for a copy of my daughter’s birth certificate. The relevant information is as follows: Name:       Date of Birth:       Place of Birth:       Father:       Mother:       Mother’s maiden name:       Thank you for your attention and cooperation. Date:       Signature of Party       Printed Name       Address       City, State, and Zip       Telephone Number MISSISSIPPI STATE DEPARTMENT OF HEALTH VITAL RECORDS P.O. Box 1700 Jackson, Ms 39215-1700 Dear Sir or Madam: I have enclosed a certified copy of JUDGMENT AUTHORIZING MODIFICATION OF BIRTH CERTIFICATE dated __________________ , authorizing the modification of the name of       as follows: From:       To:       The relevant information regarding the current birth certificate is as follows: Name:       Date of Birth:       Place of Birth:       Father:       Mother:       Mother’s maiden name:       Thank you for your attention and cooperation. Date:       Signature of Party       Printed Name       Address       City, State, and Zip       Telephone Number