Fillable Printable Illinois Affidavit of Correction Request Instructions

Illinois Affidavit of Correction Request Instructions

STATE OF ILLINOIS AFFIDAVIT AND CERTIFICATE OF CORRECTION REQUEST

INSTRUCTIONS

1. Clearly print with a black pen or type all information.

2. Place a check mark by the record you are seeking to correct.

3. Any alterations, use of white-out or cross-outs will void this affidavit. If an error is made, start over with a

new blank form.

4. Current Legal name means the name used at the time of the child's birth (i.e. the name after marriage,

after a court ordered name change or after a naturalization. This could also be the maiden name.).

5. Name prior to first marriage/civil union refers to the name given at birth; the maiden name or name that

appears on a person's birth record.

6. "Relationship" refers to the applicant's relationship to the individual named on the record, for example,

husband, mother, hospital birth clerk, daughter, individual serving as power of attorney or self.

7. “What you want corrected” should indicate the item (e.g., child's first name, mother's date of birth, father's

place of birth, marital status).

8. This form must be signed in the presence of a notary public. Notary publics are available at most banks

and currency exchanges for a minimal fee.

9. The following is a list of documents to include:

• Original affidavit signed by the person requesting the correction.

• A $15 check or money order made payable to IDPH.

• A copy of a non-expired, government issued photo ID of the person requesting the correction.

• Documentation required to complete the correction requested. Please visit our website at

http://www.idph.state.il.us/vitalrecords/correctioninfo.htm for more information concerning the types of

documents needed.

• Return all documents to:

ILLINOIS DEPARTMENT OF PUBLIC HEALTH

Division of Vital Records

925 E. Ridgely Ave.

Springfield, IL 62702-2737

If you have additional questions, e-mail them to [email protected]

IOCI 14-435

State of Illinois

Illinois Department of Public Health

Printed by Authority of the State of Illinois

P.O.1414138 5M 12/13

State of Illinois

Illinois Department of Public Health

STATE OF ILLINOIS AFFIDAVIT AND CERTIFICATE OF CORRECTION REQUEST

Requesting correction to:  Birth  Stillbirth/Fetal Death  Death

I, ____________________________________________________ being duly sworn, deposes and says under

(current legal name of applicant completing the affidavit)

penalty of perjury, that my relationship to the individual named on the record is ____________________________.

(relationship such as self, mother,

son, funeral director)

I further affirm that, FIRST; the information below lists the particulars of the record in question.

Name currently on record ___________________________________________________________________

Place of birth or death _______________________________________ Date of birth or death ____________

(facility, city and county) (month, day and year)

Mother/Co-parent’s name prior to first marriage/civil union ___________________________________________

Father/Co-parent’s name prior to first marriage/civil union __________________________________________

(if listed on the record)

SECOND; the following information is incorrect or missing and should be corrected as follows:

(Make sure to specify if you want to correct Current Legal Name or Name Prior to First Marriage/Civil Union)

What you want corrected How it reads now How it should read

________________________ ______________________________ _____________________________

(if additional room is needed, complete another affidavit/request form)

THIRD; that the applicant’s current address is:

Street address, apartment, floor, or suite number _________________________________________________

City, state and ZIP code _________________________________________ Date signed ________________

Written signature __________________________________________________________________________

(of applicant completing the affidavit)

Subscribed and sworn to before me this ________________ day of _____________________ , 20 _____

in ____________________________________ County.

NOTARY SEAL _________________________________________

(Notary Public)

_________________________________________________________________________________________

DO NOT WRITE BELOW THIS LINE.

_______________________________________________________ Date made _______________________________

Accepted for filing on the __________ day of _______________ 20 ______ By ______________________________

Title ______________________________