DOH 422-144 July 2022
Request to Change Sex Designation
on a Birth Certificate for a Minor
DOH 422-144 July 2022
Who may request a change?
A minor who was born in Washington State and wants to change their sex designation on their birth certificate
may request the change using this form.
What is required under WAC 246-490-075?
Minors (under 18 years of age and not emancipated)
• The request form must be completed and signed by a parent or legal guardian on behalf of the minor
wanting to change the sex designation on their birth certificate. Legal guardians acting on behalf of the
minor must include proof of legal guardianship (i.e. certified court order).
• The request form must be signed by a licensed health care provider, including licensed mental health care
provider, whose scope of practice allows them to determine that the requested change is consistent with the
minor’s identity.
Applicable Fees
There is no fee to amend the record.
If you would like to order a certificate with a correction request send completed Certificate Order Form with your
correction request with a check /money order for $25. Include all required documents referenced on the
instruction page for the certificate. The certificate will be issued after processing the correction.
Exchanging a certificate: If you currently have a certified copy of a certificate that was issued less than
one year ago, send in the certified copy of the certificate with this correction request; we will exchange the
certificate at no charge.
Additional Information
If your child is under 18 years old and you have not legally changed their given first and middle names, you can
submit an Affidavit for Correction with consent of all listed parents to change the first and middle names. If your
child’s name has been legally changed on their birth certificate, you must provide a certified legal name change
court order with this request form. If you want their full current legal name amended on their birth certificate,
indicate by checking the appropriate box. Additional proof documentation might be requested. For information on
legally changing their name, please visit our website at www.doh.wa.gov/VitalRecords.
Use by government agencies
At this time we are unsure if other agencies, such as Passport, will accept these amended certificates. For those
that include change of sex, nothing on the record will indicate a change was made. This will make it difficult to
connect the current record with the previous name on other documentation. In some cases, a court order might
be needed for full use of the new name and sex designation.
Mailing the form:
Center for Health Statistics
Department of Health
PO Box 47814
Olympia WA 98504
Phone: 360-236-4300
Email: VitalRecordsCorrections@doh.wa.gov
Web: www.doh.wa.gov/VitalRecords
DOH 422-144 July 2022
Request to Change Sex Designation
on a Birth Certificate for a Minor
CLEARLY PRINT OR TYPE INFORMATION. See the front-page Information Sheet for instructions and further details.
WARNING: Willfully providing a false statement to the Department of Health for a certificate is a gross misdemeanor under
Washington law. RCW 70.58A.590(2).
Complete in Ink
Office Use Only
Certificate Number Fee Number Date Amended Staff Initials Amendment Number
Applicant’s Information
First name
(as appears on Birth Certificate)
Middle name
(as appears on Birth Certificate)
Last name
(as appears on Birth Certificate)
Full current legal name (if different, submit certified legal name change court order)
Amend name on birth certificate?
Yes No
Date of Birth
(MM/DD/YYYY)
Place of Birth
(City or County)
Mother/ Parent 1 name as it appears on Birth Certificate
(First, Middle, Last)
Father/ Parent 2 name as it appears on Birth Certificate, if applicable (First, Middle, Last)
Mailing Address
(Address, City, State, ZIP code, Country)
Daytime phone
( ) -
Email Address
What sex designation is currently shown on the birth certificate?...................................... Male Female X
What sex designation are you requesting to show on the birth certificate?........................ Male Female X
I authorize the licensed health care provider listed in the health care provider section to release information related to this request. I certify under
penalty of perjury under the laws of the State of Washington (chapter 9A.72 RCW) that the foregoing is true and correct.
X
Parent/ Legal Guardian signature Relationship to minor Date signed
Health Care/ Mental Health Care Provider Attestation
This section must be completed by a licensed health care provider or licensed mental health care provider, whose scope
of practice allows them to determine that the requested change is consistent with the minor’s identity.
Your name as it appears on your license
Credential type
Professional License number
Expiration date
Issuing state/jurisdiction
Phone number
( ) -
Email Address
Attest to the following:
1. I attest that I have a provider / patient relationship with the minor…...…..………………………………….. Yes No
2. I attest that the requested designation is consistent with the minor’s identity…………………………….……..
Yes No
By signing and submitting this document to the Department of Health, I certify under penalty of perjury under the laws of the State of Washington
(chapter 9A.72 RCW) that the foregoing is true and correct.
X
Health care provider signature Print name Date signed
