TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER e: VITAL RECORDS
PART 500 ILLINOIS VITAL RECORDS CODE
SECTION 500.APPENDIX H AFFIDAVITS



Section 500.APPENDIX H Affidavits

 

Section 500.ILLUSTRATION A Affidavit by Mother

 

STATE OF ILLINOIS

DEPARTMENT OF PUBLIC HEALTH

DIVISION OF VITAL RECORDS

SPRINGFIELD 62702-5097

NOTE: A CERTIFIED COPY OF YOUR MARRIAGE RECORD MUST ACCOMPANY THE COMPLETED AFFIDAVITS. AFFIDAVITS MUST BE SIGNED BEFORE A NOTARY PUBLIC OR THEY WILL NOT BE ACCEPTED.

AFFIDAVIT BY MOTHER

STATE OF

 

SS

 

COUNTY OF

 

 

being duly sworn, deposes and says:

(Name of person making affidavit)

 

FIRST: that she is

 

years of age and resides at

 

Street

in the City of

 

, State of

 

SECOND: that she is the mother of

 

a (fe)male child

and that said child was born on

 

day of

 

, 19

 

, in the City of

 

,

County of

 

, State of Illinois, and in

 

Hospital,

and at that time she age her name as

 

for the purpose of recording its birth.

THIRD: that the natural father of said child is

 

and that she was married to said father on the

 

day of

 

, 19

 

at

 

, State of

 

.

(City, town or county)

 

FOURTH: that she now requests that a certificate of birth be prepared and filed showing said child to be the

legitimate child of

 

and the child's new name as

 

 

CHILD'S NAME

FIRST

MIDDLE

LAST

FIFTH: that the following are the PERSONAL PARTICULARS CONCERNING THE MOTHER:

Mother's maiden name:

 

 

Date of birth

 

Color or race

 

 

Occupation when child was born

 

Place of birth

 

 

Social Security Number

 

 

 

 

Signature of Mother

Subscribed and sworn to before me this

 

day of

 

, 19

 

.

 

 

 

Notary Public

 

 

VR-171 (1991r)

ILLINOIS DEPARTMENT OF PUBLIC HEALTH DIVISION OF VITAL RECORDS SPRINGFIELD 62702-5097

 

(Source: Added at 15 Ill. Reg. 11706, effective August 1, 1991)