Illinois Administrative Code (Last Updated: March 27, 2024) |
TITLE77. PUBLIC HEALTH |
PART500. ILLINOIS VITAL RECORDS CODE |
Section500.APPENDIX H. Affidavits |
§500.ILLUSTRATION B. Affidavit by Father
-
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 FATHER:
STATE OF
SS
COUNTY OF
being duly sworn, deposes and says:
(Name of person making affidavit)
FIRST: that he is
years of age and resides at
Street
in the City of
, State of
SECOND: that he is the natural father of
a (fe)male child,
and that said child was born on the
day of
, 19
in the City of
, County of
, State of Illinois, and in
Hospital, to
(Maiden name of mother)
THIRD: that he was married to the said mother on the
day of
, 19
at
, State of
(City, town or county)
FOURTH: that he 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 FATHER:
Color or race
Place of birth
Date of birth
Occupation when child was born
Social Security Number
Signature of father
Subscribed and sworn to before me this
day of
, 19
Notary Public
VR-172 (1991r)
ILLINOIS DEPARTMENT OF PUBLIC HEALTH – DIVISION OF VITAL RECORDS – SPRINGFIELD 62702-5097
(Source: Added at 15 Ill. Reg. 11706, effective August 1, 1991)