Mississippi Affidavit to Amend Certificate of Live Birth (Form 1126)
Official state formCorrections and amendmentsForm Form 1126Free downloadLast verified November 10, 2026
Sworn affidavit signed by two people before a notary to correct a Mississippi birth certificate. It is mailed to the Correction Unit of the Mississippi State Department of Health, Vital Records.
Who can use this form
- The person named on the birth certificate, plus one reputable person who knows the facts of the birth.
- Both must sign in front of a notary public.
- If the person is under 18, a parent or legal guardian (with proof of guardianship) signs instead, plus one reputable person with knowledge.
- State law covers missing information and a wrong first name, middle name or sex. Other changes follow a different section of the law.
What to send with it
- The notarized affidavit with original signatures. Copies are not accepted.
- One supporting document at least 5 years old that shows the correct name and age or date of birth, such as a physician or school record, passport, old driver's license, DD214, immunization record or the child's birth certificate.
- The $28.00 fee by money order, personal check or cashier's check. Do not send cash.
- Any other documents the office requires. Sending the form does not guarantee the amendment.
Where to send it
- Mail to
- MS Vital Records P O Box 1700 Jackson, MS 39215 ATTN: Correction Unit
- State fee
- $28.00, which includes one certified copy of the amended record. Extra copies are $6.00 each when ordered at the same time for the same person. The form says it accepts personal checks, while the office's certified-copy instruction pages say no personal checks.
- Typical processing
- Not provided
- Form revision
- Revised 12/13/18
- Source
- Official government page