12 Ioci 158 Form – Fill Out and Use This PDF

STATE OF ILLINOIS

Illinois Department of Public Health

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 dph.vitals@illinois.gov

Printed by Authority of the State of Illinois

P.O.1412123 10M 2/12

IOCI 12-158

STATE OF ILLINOIS

Illinois Department of Public Health

STATE OF ILLINOIS AFFIDAVIT AND CERTIFICATE OF CORRECTION REQUEST

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

I, ____________________________________________________ being duly sworn, deposes and says under

(name of applicant completing the affidavit)

penalty of perjury, that my relationship to the individual named in 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 legal name prior to first marriage/civil union _______________________________________

Father/Co-parent’s legal 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:

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 _______________________________
_______________________________________________________	Date made _______________________________
_______________________________________________________	Date made _______________________________
_______________________________________________________	Date made _______________________________

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

Title ______________________________