Application For Gender Reassignment - Illinois Department Of Public Health (Page 3 of 4) in pdf

Application For Gender Reassignment - Illinois Department Of Public Health Page 3

State of Illinois

Illinois Department of Public Health

AFFIDAVIT BY PHYSICIAN VERIFYING COMPLETION

OF GENDER REASSIGNMENT

State of _________________________:

County of ________________________:

I, _____________________________________________________ M.D./D.O., being duly sworn on oath and

acknowledging the criminal penalties of perjury and filing a false affidavit, state that I am licensed in good standing

to practice medicine in the U.S. state of ____________________________ and that I have personally examined

_________________________________ (name of applicant). By reason of that examination, I verify that the

following named operation(s) previously performed, (list the name of the operation(s)) ___________________,

________________________________________________________________________________________

on ________________________________________________(name of applicant), has reassigned the gender

from _______________ to _______________ and by reason of that operation(s), justifies a gender change on

the applicant’s birth certificate.

Signature of Physician ______________________________________________________________________

PHYSICIAN’S INFORMATION

License number _______________________ Issuing state _______________________________________

Office street address _______________________________________________________________________

Office city, state and ZIP code ________________________________________________________________

Office telephone and facsimile numbers ________________________________________________________

Subscribed and sworn to before me this ___________ day of _____________________________, 20______.

_____________________________________

Notary Public Signature

Notary Public Stamp or Seal

IOCI 12-402

Printed by Authority of the State of Illinois

Application For Gender Reassignment - Illinois Department Of Public Health Page 3