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Illinois Affidavit And Certificate of Correction Request

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Illinois Affidavit And Certificate of Correction Request
Illinois Affidavit And Certificate of Correction Request
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.
4. "Relationship" refers to the applicant's relationship to the individual named on the record, for example,
husband, mother, hospital birth clerk, daughter or individual serving as power of attorney.
5. 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).
6. 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.
7. The following is a list of documents to include:
Original affidavit signed by the person completing the affidavit.
A $15 check or money order made payable to IDPH for one certified copy of the corrected record.
A copy of a non-expired, government issued photo ID of the person completing the affidavit.
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, please e-mail them to [email protected]
IOCI 12-158
State of Illinois
Illinois Department of Public Health
Printed by Authority of the State of Illinois
P.O.1412123 10M 2/12
Illinois Affidavit And Certificate of Correction Request
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