Illinois Administrative Code (Last Updated: March 27, 2024) |
TITLE77. PUBLIC HEALTH |
PART500. ILLINOIS VITAL RECORDS CODE |
Section500.APPENDIX H. Affidavits |
§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)