Ill. Admin. Code tit. 77, pt. 500, app A, ILLUSTRATION F

Current through Register Vol. 49, No. 2, January 10, 2025

Application for Correction of a Birth Certificate

APPLICATION FOR CORRECTION OF A BIRTH CERTIFICATE

MAIL TO:	Illinois Department of Public Health
Office of Vital Records
605 West Jefferson
Springfield, Illinois 62761

I wish to have errors corrected on the birth certificate identified as follows:

FULL NAME

OF CHILD:

____________________________________________________

PLACE

OF BIRTH:

______________________________________________________

HOSPITAL

COUNTY

CITY, VILLAGE, TOWNSHIP

DATE

REGISTERED

STATE FILE

OF BIRTH:

__________________

NUMBER

_______

NUMBER

_______

MONTH

DAY

YEAR

MOTHER'S

MAIDEN NAME:

______________________________________________________

FATHER'S NAME AS

LISTED ON BIRTH RECORD:

______________________________________________________

Please give us the INCORRECT and CORRECT information below:

INCORRECT INFORMATION

CORRECT INFORMATION

SHOULD READ _______________________________________________________________________

PRINT

PRINT

SHOULD READ _______________________________________________________________________

PRINT

PRINT

SHOULD READ _______________________________________________________________________

PRINT

PRINT

SHOULD READ _______________________________________________________________________

PRINT

PRINT

SHOULD READ _______________________________________________________________________

PRINT

PRINT

ADDITIONAL COMMENTS:

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Please mail correction forms to:

WRITTEN SIGNATURE:

____________________________

ADDRESS: __________________

__________________

DATE:

__________________

MY RELATIONSHIP TO CHILD:

___________________

VR - 401.1 REV. 6/75

Ill. Admin. Code tit. 77, pt. 500, app A, ILLUSTRATION F

Added at 15 Ill. Reg. 11706, effective August 1, 1991