FormDownload Logo
Powered By: FormSwift Lease Agreement

Free Illinois Affidavit and Certificate of Correction Request Form

Forms in Affidavits

Use this template/form as an Affidavit and Certificate of Correction Request Form in the State of Illinois

illinois-affidavit-and-certificate-of-correction-request

 Advertisements

Text version of this Form

———————– Page 1———————–

State of Illinois
Illinois Department of Public Health

STATE OF ILLINOIS AFFIDAVIT AND CERTIFICATE OF CORRECTION REQUEST
INSTRUCTIONS

1. Clearly print with a black pen or type all information.

2. Place a check mark by the record you are seeking to correct.

3. Any alterations, use of white-out or cross-outs will void this affidavit.

4. “Relationship” refers to the applicant’s relationship to the individual named on the record, for example,
husband, mother, hospital birth clerk, daughter or individual serving as power of attorney.

5. “What you want corrected” should indicate the item (e.g., child’s first name, mother’s date of birth, father’s
place of birth, marital status).

6. This form must be signed in the presence of a notary public. Notary publics are available at most banks
and currency exchanges for a minimal fee.

7. The following is a list of documents to include:

• Original affidavit signed by the person completing the affidavit.

• A $15 check or money order made payable to IDPH for one certified copy of the corrected record.

• A copy of a non-expired, government issued photo ID of the person completing the affidavit.

• Documentation required to complete the correction requested. Please visit our website at
http://www.idph.state.il.us/vitalrecords/correctioninfo.htm for more information concerning the types of
documents needed.

• Return all documents to:

ILLINOIS DEPARTMENT OF PUBLIC HEALTH
Division of Vital Records
925 E. Ridgely Ave.
Springfield, IL 62702-2737

If you have additional questions, please e-mail them to dph.vitals@illinois.gov

Printed by Authority of the State of Illinois
P.O.1412123 10M 2/12
IOCI 12-158

———————– Page 2———————–

State of Illinois
Illinois Department of Public Health

STATE OF ILLINOIS AFFIDAVIT AND CERTIFICATE OF CORRECTION REQUEST

Requesting correction to:  Birth  Stillbirth/FetalDeath  Death

I, ____________________________________________________being duly sworn, deposes and says under
(name of applicant completing the affidavit)

penalty of perjury, that my relationship to the individual named in 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 legal name prior to first marriage/civil union_______________________________________

Father/Co-parent’s legal 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:

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 ______________________________


 Advertisements

Review Illinois Affidavit and Certificate of Correction Request Form

Name
Email
Review Title
Rating
Review Content

Illinois Affidavit and Certificate of Correction Request Form Reviews

 Advertisements