New Jersey Department of Health

Office of Vital Statistics and Registry

P.O. Box 370

Trenton, NJ 08625-0370

ATTESTATION TO BIRTH CERTIFICATE

NOTE: THIS DOCUMENT IS NOT TO BE USED FOR IDENTIFICATION OR LEGAL PURPOSES.

1.	You have the legal right to choose any name for your child. N.J.A.C 8:2-1.4: The designation of a child's name including the surname is the right of the child's parent(s). The child may be given any chosen name(s) or surname, except that the State Registrar may reject a name that contains an obscenity, numerals, symbols, or a combination of letters, numerals, or symbols, or a name that is illegible. After you have chosen the name and it is put on the birth certificate, it cannot be changed except through a court of law.

2.	Please review the name you have chosen for your child and demographic information provided below and then sign your name.

3.	If a father is listed on the record, he must sign the form as well.

4.	If the parents are unmarried, a Certificate of Parentage form must have been submitted to permit the Father’s information to appear on the birth certificate.

5.	If the husband is not the father, and wishes to deny paternity, both the mother and the husband must first complete an Affidavit of Denial of Paternity. Then the mother and the biological father must complete and sign a Certificate of Parentage. If both forms are not completed, the husband’s information will appear on the birth certificate.

A.	By affixing our signatures below, we (I) agree to the choice of our child’s name and demographic information provided below. We (I) understand that once the choice is made, it cannot be changed except by a court order.

B.	Also, we (I) acknowledge that the child’s name and other personal information that appears has been reviewed and verified.

Name of Mother (Print)

Signature of Mother	Date
Name of Father (Print)

Signature of Father	Date

1. Name of Child (First)	(Middle)	(Last)	(Suffix)

2a. Date of Birth (MM/DD/YYYY)

2b. Time of Birth

____:____ M	3. Sex

Male

Female	4a. Plurality

Single Twin

Other (specify) ___________	4b. If Multiple Birth, Birth Order:

1st 2nd

Other (specify) ___________
5a. Place of Birth (Name of facility, if not institution, give Street Name and Number)

5b. Municipality of Birth

5c. County of Birth

6. Mother’s Name (First)	(Middle)	(Last)

(List name given at birth or on birth certificate/Maiden name)

7. Mother’s Date of Birth (MM/DD/YYYY)

8. Mother’s Legal Name (First)	(Middle)	(Last)

9. Mother’s Birthplace (State or Foreign Country)

10a. Mother’s Residency Address (Number and Street Name)

10b. Residence (City, Township or Boro)

10c. County

10d. State

10e. Inside City Limits

Yes No
11a. Mother’s Mailing Address (Number and Street/PO Box Number)

11b. City or Township

11c. State

11d. Zip Code

12a. Father’s Name (First)	(Middle)	(Last)	(Suffix)

12b. Father’s Date of Birth (MM/DD/YYYY)

12c. Father’s Birthplace (State or Foreign Country)

13a. Father’s Mailing Address (Number and Street/PO Box Number)

13b. City or Township

13c. State

13d. Zip Code

14a. Name of Informant

14b. Relationship to Child

NOTE: THIS DOCUMENT IS NOT TO BE USED FOR IDENTIFICATION OR LEGAL PURPOSES.

REG-40

NOV 16

REG-40, Attestation to Birth Certificate

ewhite

2016-11-21

NJDOH