Illinois Affidavit And Certificate Of Correction Request
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2State 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. If an error is made, start over with a
new blank form.
4. Current Legal name means the name used at the time of the child's birth (i.e. the name after marriage,
after a court ordered name change or after a naturalization. This could also be the maiden name.).
5. Name prior to first marriage/civil union refers to the name given at birth; the maiden name or name that
appears on a person's birth record.
6. "Relationship" refers to the applicant's relationship to the individual named on the record, for example,
husband, mother, hospital birth clerk, daughter, individual serving as power of attorney or self.
7. “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).
8. 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.
9. The following is a list of documents to include:
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Original affidavit signed by the person requesting the correction.
•
A $15 check or money order made payable to IDPH.
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A copy of a non-expired, government issued photo ID of the person requesting the correction.
•
Documentation required to complete the correction requested. Please visit our website at
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, e-mail them to dph.vitals@illinois.gov
Printed by Authority of the State of Illinois
P.O.1414138
5M
12/13
IOCI 14-435
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