Form A3 - Birth Record Request Form

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VITAL RECORDS
COOK COUNTY
OFFICE OF COOK COUNTY CLERK DAVID ORR
CLERK
P.O. Box 641070, Chicago, Illinois 60664-1070
VITAL RECORDS
312.603.7790
tel
email
web
BIRTH RECORD REQUEST FORM - FORM A3
A certified copy of a birth record is available at no cost to persons born in Cook County, who are verified as
either: homeless; residents of shelters for victims of domestic abuse/violence; and formerly incarcerated or
soon to be released inmates or detainees of the Illinois Department of Corrections or Cook County Jail.
Please select one of the following:
Incarcerated
(currently or
Homeless
Survivor of Domestic Abuse
within the past 90 days)
Name at birth
First Name
Middle Name
Last Name
Date of birth
Place of birth
Month/Day/Year
City or Village (in Cook County)
Name of mother
Last Name (at time of birth)
First Name
(if adopted, mother’s name at time of adoption)
Name of father
Last Name
First Name
(optional)
Under Illinois law [410 ILCS 535/25 (4) (b)] a certified copy of a birth record is only available to persons with a “direct and
tangible interest” in the record, such as one’s self, parent, guardian or legal representative. Anyone who willfully and
knowingly uses or attempts to use any certificate and/or certification for the purposes of deception is guilty of a Class 4
felony [410 ILCS 535/27 (c), (f)] punishable up to three years in prison.
Your name (print)
Last Name
First Name
Signature
Telephone Number
Mailing address
Street Address
City, State, Zip
Relationship to child
(if applicable)
How would you like to receive this document?
Mail it to me
I’ll wait for it today
I’ll pick it up at a later date
*if requesting the document by mail, please include: 1) a photocopy of your photo identification; 2) a self-addressed stamped envelope
see back for more details

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