Form A3 - Birth Record Request Form Page 3
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1
2
3VITAL 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
STATUS CERTIFICATION
The Status Certification is provided for the listed agent or agency to affirm to the named individual’s status at
the time this certification is completed. It must be received by the Cook County Clerk’s office at the time of
application. This certification entitles the individual to a free birth certificate.
Please select one of the following:
Incarcerated
(currently or
Homeless
Survivor of Domestic Abuse
within the past 90 days)*
Applicant’s Name
First Name
Middle Name
Last Name
Date of birth
Month/Day/Year
I am an individual who falls under the above checked category and reside or receive services from the agency whose
name and address are indicated on this document.
Signature
Date
*release papers may be provided as proof of status and therefore agency information is not required.
To be completed by agency/agent:
Agency/Agent Name
Telephone Number
Mailing address
Street Address
City, State, Zip
Agency Federal Tax ID Number or Attorney Registration Number
Under penalty of perjury, I swear or affirm that I am a representative of the above-referenced Agency and the applicant
is a person who is currently residing or receiving services from this Agency.
Printed Name of Agency Employee/Agent Making Certification
Signature
Date
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