Washington Packet to Register an Unattended Home Birth (DOH 422-121)
Official state formDelayed registrationForm DOH 422-121Free downloadLast verified November 10, 2026
This packet is for registering a child under one year old who was born at home without a licensed midwife or medical professional. The forms go to the Center for Health Statistics at the Washington State Department of Health and must be postmarked before the child's first birthday.
Who can use this form
- Parents of a child under one year old who was born at home without a licensed midwife or medical professional
- The attendant who signs the birth filing form must be over 18 and cannot be the mother or person who gave birth
- If the child is over one year old, the packet says to contact the Department of Health to register a delayed report of live birth
What to send with it
- The Washington State Birth Filing form (DOH 422-020) in black ink, items 1 to 38 and item 70
- One original Supporting Affidavit (DOH 422-036), signed in front of a notary public
- Copies of identity documents for the attendant, the mother or person who gave birth, and the father or second parent if listed
- Proof that the mother or person who gave birth lived in Washington State within 30 days of the birth
- An Acknowledgment of Parentage, if it applies
Where to send it
- Mail to
- Center for Health Statistics PO Box 47814 Olympia, WA 98504-7814
- State fee
- Not provided
- Typical processing
- Not provided
- Form revision
- February 2021
- Source
- Official government page