Ill. Admin. Code tit. 77, § 500.APPENDIX A – Birth Records

Section 500.ILLUSTRATION F 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

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

ADDITIONAL COMMENTS:

Please mail correction forms to:

WRITTEN SIGNATURE:

ADDRESS:

DATE:

MY RELATIONSHIP TO CHILD:

VR – 401.1 REV. 6/75

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