Fillable Printable Application for Search of Birth Record Files - Illinois

Application for Search of Birth Record Files - Illinois

ELIGIBILTYTO OBTAIN AN ILLINOIS BIRTH RECORD

Before a request for a copy of a birth record can be considered you must specify your eligibility to obtain it.

ILCS410/535/25(4) states that copies of birth records may only be issued upon:

•The order of a court of competent jurisdiction

•The specific written request for a certification or certified copy by the person, if of legal age (18 or older), or by a

parent or other legal representative* of the person to whom the record of birth relates; or

•The specific writtenrequestfora certificationor certifiedcopy bya department ofthestate, a municipal corporation,

or the federal government

*77 Illinois AdmCode 500.10 refers to “Legal representative” as

•An attorney acting on behalf of a person(s) named on a birth certificate;

•An agent authorized by power of attorney;

•Acourt-appointed personal representative;

•An agent with written, notarized authorization from a person(s) named on a birth certificate for the purpose of obtaining a

certified copy or certification for that person; or

•Any other agent, approved bytheState Registrar asalegalrepresentativeof the personto whomthebirthcertificate relates.

NOTE:Any person who, willfully and knowingly uses or attempts to use, or furnishes to another for use, for any purpose

of deception, anycertificate, record, report, certification or certifiedcopy thereofso made,altered, amended,or mutilated; or,

Any person who with the intention to deceive, willfully uses or attempts to use any certification or certified copy of a

record of birth knowing that such certification or certified copy was issued upon a record that is false in whole or in part

or that relates to the birth of another person, is guilty of a Class 4 felony in the state of Illinois (ILCS 410/535/27(f)).

ACCEPTABLE PROOF OF ID

ANON-EXPIRED, GOVERNMENT ISSUED PHOTO ID, such as a driver's license. If you have an extension sticker on

your license, submit a copy of both sidesof the license. If you do not have a driver's license, a photo ID Card issued

by the Department of Motor Vehicles can be provided.

If your driver's license or ID Card is expiredor not available,youmust submit TWO (2) piecesof documentationwith

yourname on them. In addition to your name, one piece must also have your current address on it to prove your identity.

ONE piece of documentation can be a bill or other USPS mail; the SECOND must be one of the items listed below:

•Medical/car insurance card•Bank statement

•Credit card statement•Public assistance card

•Paycheck stub with imprinted information•Active duty military ID w/ issued and expiration dates

•Voter’s registration card•EBT Link Card (Illinois Electronic Benefit Transfer)

•Car registration paperwork

SOCIALSECURITY CARDS ARE NOT ACCEPTABLE

Matrícula Consular card issued after October 2006 is acceptable on its own. However, if issued prior to

October 2006, we need ONE additional type of documentation showing current address as noted above. If

you do not have any of the items listed above, please submit a copy of a current utility bill (electricity, cellular

phone, water, etc.) showing your name and current address.

If you are currently incarcerated, you can submit a dated copy of your prison intake/offender summary sheet

containing your photo. If you have been released from prison within the last six months, a copy of the release

papers along with the prison photo ID will be accepted.

If you are writing from a state or federal agency, you can submit a copy of your photo work badge with issued

and expiration dates.

State of Illinois

Illinois Department of Public Health

NOTE:Birth Certificates are confidential records and copies can onlybe issued to persons entitled to receive them (for a complete

list, see other side). The application must indicate the requestor’s relationship to the person and the intended use of the document.

(SEE OTHER SIDE)

VR 180 (Rev. 2/15)

Printed by Authority of the State of Illinois P.O.#1415146 3M 2/15 IOCI 15-571

INDIVIDUALREQUESTING COPIES

PRINTNAME____________________________________________

STREET ADDRESS _______________________________________

CITY_____________________STATE ______ZIP___________

YOUR RELATIONSHIPTO PERSON_________________________

INTENDED USE__________________________________________

SIGNATURE_____________________________________________

MAILRECORD(S) TO: (If other than applicant)

NAME___________________________________________

AGENCY________________________________________

STREET ADDRESS________________________________

CITY____________________________________________

STATE ______ZIP_____________

FULLNAME(First, Middle, Last Prior to First Marriage/Civil Union)

PLACE OF BIRTH(Hospital, City or Town, County, State)

DATE OF BIRTH(Month, Day, Year)SEXBIRTH CERTIFICATE NUMBER(if known)

FATHER/CO-PARENT'S NAME(First, Middle, Last Prior to First Marriage/Civil Union, Current Legal Last Name)

MOTHER/CO-PARENT'S NAME(First, Middle, Last Prior to First Marriage/Civil Union, Current Legal Last Name)

MAILTO: Illinois Department of Public Health, Division of Vital Records, 925 E. Ridgely Avenue, Springfield, IL 62702-2737

For more information - www.idph.state.il.us/vitalrecords/index.htm

State of Illinois

Illinois Department of Public Health

Application for Search of Birth Record Files

The state began recording birth records on January 1, 1916.

TheDivision ofVital Records offers two types of birth certificatesavailable for legal purposes.

Please indicate your choice below and return this form with the proper fee and a legible copy of your non-expired, government

issued photo ID.

Illinois Law (ILCS410/535/25(1)) requires advanced payment for the search of birth record files. This $10.00 search fee, included in

the price of the copy(ies) you are requesting, is non-refundable.

DO NOT SEND CASH – Make check or money order payable to: ILLINOIS DEPARTMENT OF PUBLIC HEALTH

Birth certificate(with the following items: name, date of birth, sex,

place of birth, mother/co-parent's maiden name,

mother/co-parent's place of birth, mother/co-parent's age,

father/co-parent’s name, father/co-parent's place of birth,

father/co-parent's age, file date, date issued and State File number)

$10.00 first copy $2.00 each additional copy

Amount enclosed $__________ for ________ total copies

Birth certificate(with available information collected at time of birth

- information has varied throughout the years)

$15.00 first copy $2.00 each additional copy

Amount enclosed $__________ for ________ total copies

Foreign birth(births of adopted persons born outside of the U.S.

who were re-adopted in Illinois)OR

ADMINISTRATIVE FOREIGN BIRTH RECORD

$5.00 each copy

Amount enclosed $__________ for ________ total copies

Genealogical(uncertified) (records 75 years old and older)

$10 first copy $2 each additional copy

Amount enclosed $__________ for ________ total copies