Form A3 - Birth Record Request Form Page 2
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3BIRTH 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.
Formerly incarcerated citizens who have been paroled within the past 90 days can attach a copy
of their release papers for verification. Homeless residents, residents of shelters for domestic
violence, soon to be released inmates or the formerly incarcerated who have been released
in the last 90 days can also have their status verified by a human services, corrections officer,
legal services, or other worker that has knowledge of the individual’s status. This includes: a
homeless service agency, a domestic violence shelter, an attorney licensed to practice in Illinois,
a public school homeless liaison or school social worker or a human services provider.
Two ways to obtain a birth record:
1.
By Mail
Fill out this form and mail your request to:
Bureau of Vital Records
P.O. Box 641070
Chicago, IL 60664-1070
Fill out the form on the reverse side and include:
• A photocopy of your photo identification (e.g. driver’s license, or
State issued identification, etc.)
• A self-addressed stamped envelope
2.
In-person, at the Cook County Clerk’s Office:
50 W. Washington St. (Pedway Level, under the Daley Center)
Or visit one of our five suburban offices. Call (312) 603-7790 or go to
for locations and hours.
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