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

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State of Illinois
Illinois Department of Public Health
AFFIDAVIT BY PHYSICIAN VERIFYING COMPLETION
OF GENDER REASSIGNMENT
State of _________________________:
SS
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

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