Application For Gender Reassignment - Illinois Department Of Public Health printable pdf download

State of Illinois

Illinois Department of Public Health

STATE OF ILLINOIS GENDER REASSIGNMENT APPLICATION INSTRUCTIONS

After a gender reassignment operation(s) by a U.S. licensed physician, the Affidavit by Physician after Completion

of Gender Reassignment must be completed by the physician who performed the operation(s) and the Affidavit

for a New Birth Certificate after Completion of Gender Reassignment must be completed by the applicant.

Each affidavit must be notarized and the original submitted to this office. Please note that genital reconstructive

surgery is not required to obtain a change in the sex designation on an Illinois birth certificate.

After a gender reassignment operation(s) performed outside of the United States, the Affidavit by Physician

Verifying Completion of Gender Reassignment Operation must be completed by an examining physician duly

licensed to practice medicine in Illinois or any other state in the United States. This form can also be used if the

physician who performed the operation is no longer practicing, is unavailable or his/her license has been

revoked or expired.

he Affidavit for a New Birth Certificate after Completion of Gender Reassignment must

be completed by the applicant. Each affidavit must be notarized and the original submitted to this office.

If you have had a legal name change by court order that has NOT been reflected on your birth certificate, include

a certified copy of the court order. Make sure to check the appropriate box on the Affidavit for a New Birth

Certificate after Completion of Gender Reassignment to indicate your request to have your name changed. If

you do not include a certified copy of that court order of legal name change, the new birth certificate will reflect

the name as it currently appears on the original birth certificate.

This office will review the submitted documents and if all requirements are met, will create a new birth record

reflecting the new gender designation and name change, if appropriate. The original birth certificate and all

documents submitted are placed in a sealed and impounded file which cannot be opened except upon court

order.

The fee is $15 and includes one certified copy of the new birth certificate. Additional copies are $2 each if ordered

at the same time. Make check or money order payable to Illinois Department of Public Health.

Include a copy of your non-expired, government issued photo identification card (ID).

If you have additional questions, you can reach the Illinois Department of Public Health, Division of Vital

Records at 217-782-6553, Monday through Friday, from 10:00 a.m. to 3:00 p.m.

ILLINOIS DEPARTMENT OF PUBLIC HEALTH

Division of Vital Records

925 E. Ridgely Avenue

Springfield, IL 62702-2737

IOCI 12-402

Printed by Authority of the State of Illinois

Application For Gender Reassignment - Illinois Department Of Public Health