Ill. Admin. Code tit. 77, pt. 500, app A, ILLUSTRATION E
APPLICATION FOR SEARCH OF BIRTH RECORD FILES | ||||||||||||||||||||||||||
The fee for a search of the files is $10.00. If the record is found one CERTIFICATION or BIRTH CARD is issued at no additional charge. Additional certifications or birth cards of the same record ordered at the same time are $2.00 each. The fee for a FULL CERTIFIED COPY is $15.00. Additional certified copies of the same record ordered at the same time are $2.00 each. Please indicate below the type and number of copies requested and return this form with the proper fee. DO NOT SEND CASH. Make check or money order payable to: Illinois Department of Public Health. | ||||||||||||||||||||||||||
CERTIFIED COPY | CERTIFICATION | BIRTH CARD (wallet size) | ||||||||||||||||||||||||
$15.00 Each | $10.00 Each | $10.00 Each | ||||||||||||||||||||||||
Amount Enclosed: | $ | ____ | Amount Enclosed: | $ | __________ | Amount Enclosed: | $ | ________________ | ||||||||||||||||||
for | ____ | copies | for | ____ | copies | for | ____ | copies | ||||||||||||||||||
First | Middle | Last | ||||||||||||||||||||||||
FULL NAME: | ||||||||||||||||||||||||||
PLACE OF BIRTH: | Street, RFD., Hosp. | City or Town | County | |||||||||||||||||||||||
DATE OF BIRTH: | Month | Day | Year | SEX: | BIRTH NUMBER IF KNOWN: | |||||||||||||||||||||
FATHER: | ||||||||||||||||||||||||||
MOTHER: | Maiden Name | Married Name | ||||||||||||||||||||||||
Application Made By: | Mail Copy to (if other than applicant): | ||||||||
NAME: | NAME: | ||||||||
(written signature) | |||||||||
STREET | STREET | ||||||||
ADDRESS: | ADDRESS: | ||||||||
CITY: | STATE: | ZIP | CITY | STATE: | ZIP | ||||
YOUR RELATIONSHIP TO PERSON: | INTENDED USE OF DOCUMENT: | ||||||||
Birth certificates are confidential records, and copies can be issued only to persons entitled to receive them. The application must indicate the requestor's relationship to the person and the intended use of the document.
VR. 180 (5/87R)- | DIVISION OF VITAL RECORDS-605 WEST JEFFERSON STREET-ILLINOIS DEPARTMENT OF PUBLIC HEALTH, SPRINGFIELD, ILLINOIS 62702 |
Ill. Admin. Code tit. 77, pt. 500, app A, ILLUSTRATION E