Commonwealth of Massachusetts
The Trial Court Probate and Family Court Department
PETITION FOR CORRECTION OF BIRTH RECORD
, Petitioner V. in his/her official capacity as City/Town Clerk of , Respondent .
(name of city or town)
1. Now comes the petitioner who seeks to correct the birth certificate of The child was born on in 2. Petitioner, who resides at
(name of child) (city or town of birth)
(date of birth) (county of birth)
in , Massachusetts.
is the 3. On State of
(relationship, i.e., mother, legal father) (date of judgment) (name of state)
of the child.
(name of out of state court)
, entered a judgment or order establishing the paternity of the child under
the laws of that state. A CERTIFIED copy of that judgment or order is filed with this petition. 4. On or about
the petitioner presented a certified copy of the judgment or order to the
respondent with the request that the respondent prepare a new birth certificate for the child consistent with the judgment of the Court and substitute the new certificate for the old certificate, but the respondent declined to do so. 5. Wherefore petitioner requests that this Court enter an order that the respondent prepare a new birth certificate for the child consistent with the judgment and substitute the new certificate for the old certificate, as provided by G.L. c. 46 § 13.
(Signature of attorney or plaintiff, if pro se) (Print name)
Tel. No. B.B.O. #
CJ-D 118 (4/07)