Correction Of Birth Record Form Page 2
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2Supporting Affidavits
In the Matter of the Correction of Birth Record of
_______________________________________________
State of Ohio, _______________________________________________ Affidavit of Physician
The undersigned, being first duly sworn, deposes and says the he was the physician in attendance at the birth of
________________________________________ the applicant and that the facts stated herein are true as he/she verily believes.
(Name of Applicant at Birth)
________________________________________________
(Attending Physician)
________________________________________________
(Address)
Sworn to before me and signed in my presence by the said __________________________________________________________
this ______________ day of ________________, 20___.
________________________________________________
________________________________________________
(Official Title)
NOTE: If the affidavit of the attending physician cannot be secured, the application must be supported by the following affidavit, relative or
non-relative, having personal knowledge of the facts.
State of Ohio, _______________________________________________ Affidavit
The undersigned, being first duly sworn, deposes and says that he/she is ____ years of age, that he/she has read the application and
that he/she has personal knowledge of the facts stated therein by reason of being ________________________________________
(state relationship, if any, or state facts showing personal knowledge)
and that the statements made in the application are true as he/she verily believes.
________________________________________________
(Signature of Affiant)
________________________________________________
(Address)
Sworn to before me and signed in my presence by the said __________________________________________________________
this ______________ day of ________________, 20___.
________________________________________________
________________________________________________
(Official Title)
State of Ohio, _______________________________________________ Affidavit
The undersigned, being first duly sworn, deposes and says that he/she is ____ years of age, that he/she has read the application and
that he/she has personal knowledge of the facts stated therein by reason of being ________________________________________
(state relationship, if any, or state facts showing personal knowledge)
and that the statements made in the application are true as he/she verily believes.
________________________________________________
(Signature of Affiant)
________________________________________________
(Address)
Sworn to before me and signed in my presence by the said __________________________________________________________
this ______________ day of ________________, 20___.
________________________________________________
________________________________________________
(Official Title)
HEA 2783 (REV. 8/2015)
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