Illinois Affidavit And Certificate Of Correction Request Page 2
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1
2State of Illinois
Illinois Department of Public Health
STATE OF ILLINOIS AFFIDAVIT AND CERTIFICATE OF CORRECTION REQUEST
Birth
Stillbirth/Fetal Death
Death
Requesting correction to:
I, ____________________________________________________ being duly sworn, deposes and says under
(current legal name of applicant completing the affidavit)
penalty of perjury, that my relationship to the individual named on 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 name prior to first marriage/civil union ___________________________________________
Father/Co-parent’s 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:
(Make sure to specify if you want to correct Current Legal Name or Name Prior to First Marriage/Civil Union)
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 ______________________________
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