State Of Illinois Affidavit and Certificate of Correction Request is the legal document for requesting amendment in the record of a child due to the error in the records held by the State of Illinois.
The document must be signed before the Notary Public of the state for its acceptance. Submit the duly completed Affidavit and Certificate of Correction Request to Illinois Department of Public Health, Division of Vital Records, 925 E. Ridgely Ave., Springfield, IL 62702-2737. Remittance of $15 fees by check or money order to Illinois Department of Public Health is required for the processing the request. Attach a copy of a government ID proof along with the request form.
Before You Proceed
- Use black colored ink to type or print the inputs in the Affidavit and Certificate of Correction Request.
- Check mark on the record to be corrected is necessary.
- Avoid using whiteouts, alterations, and cross outs to prevent voiding of the Affidavit and Certificate of Correction Request.
- Notarization and remittance of $15 fees are necessary for the post processing of the Affidavit and Certificate of Correction Request after its submission with Illinois Department of Public Health.
- Complete the Affidavit and Certificate of Correction Request in every sense to avoid ambiguity, delay, as well as rejection of processing.
- Do not write/type/print in the last portion of the Affidavit and Certificate of Correction Request. This space is reserved for the inputs by the officials of Division of Vital Records, Illinois Department of Public Health
Begin by marking your choice of correction from the three options listed on the foremost portion of the document. Continue by typing or printing your legal name followed by the relationship. Specify the relationship as appropriate.
The first section of the Affidavit and Certificate of Correction Request requires the input of the name currently on the record. Enter the place of birth or death on the following line. Enter the date of birth or death in the space provided for the same. Enter the names of mother and father and/or co-parent/s in the respective spaces provided for the name. Take care to enter the legal names prior to the first marriage/civil union.
The Second section of the Affidavit and Certificate of Correction Request requires the input of what you need to correct, how it reads now, and how it should read. Mention each correction on a separate line and use one more affidavit/request form if more space is required.
Enter the street address, city, state, and zip code of the applicant in section 3 of the Affidavit and Certificate of Correction Request. Continue by typing the date and sign in the space provided on the next line.
The following space is reserved for notarization and requires the inputs by the Notary Public of Illinois State.
Do not type or print in the last portion of the Affidavit and Certificate of Correction Request. It is reserved for official use.
Illinois Affidavit and Certificate of Correction Request
Text version of this Form
———————– Page 1———————–
State of Illinois
Illinois Department of Public HealthSTATE OF ILLINOIS AFFIDAVIT AND CERTIFICATE OF CORRECTION REQUEST
INSTRUCTIONS1. 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 62702-2737If you have additional questions, please e-mail them to [email protected]
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 HealthSTATE 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 ______________________________