Washington Supporting Affidavit for Births (DOH 422-036)
Official state formDelayed registrationForm DOH 422-036Free downloadLast verified November 10, 2026
A person with personal knowledge of a birth in Washington signs this affidavit in front of a notary public. It is required when registering an unattended home birth and goes to the Center for Health Statistics at the Washington State Department of Health.
Who can use this form
- The mother or person who gave birth, or someone with personal knowledge of the facts of the birth
- For an unattended home birth, it cannot be signed by the same person who signed the birth filing form as the attendant
- Personal knowledge means having seen the mother pregnant within two months before the birth and not pregnant after it, or having seen the birth
What to send with it
- The affidavit, signed in front of a notary public
- The child's full name, sex, date and place of birth, and the parents' birth names
- A detailed statement of how you know the facts, with the location of the birth and the names of those present
Where to send it
- Mail to
- Center for Health Statistics P.O. Box 47814 Olympia WA 98504-7814
- State fee
- Not provided
- Typical processing
- Not provided
- Form revision
- March 2017
- Source
- Official government page