700-00200AC – Affidavit in Support of Petition for Corrected Birth Certificate (03/2018) Page 1 of 1

STATE OF VERMONT

SUPERIOR COURT PROBATE DIVISION

Unit Docket No.

In re:

AFFIDAVIT IN SUPPORT OF PETITION FOR CORRECTED BIRTH CERTIFICATE

In support of the petition for a corrected Birth Certificate, I state under oath, I qualify under one of the following categories: ☐ Self ☐ Parent or Guardian ☐ The hospital in which the birth occurred ☐ The certifying attendant, or custodian

☐ I have the following personal knowledge to support my Petition for a corrected Birth Certificate:

Date Signature of Petitioner

Printed Name

Signed and sworn to before me:

Date Signature of Notary Public Expiration Date

Name on Certificate