18 North County Street
Waukegan Illinois 60085
847.377.2411
M - Th 8:30 a.m. – 5:00 p.m.
Fri 8:30 a.m. – 7:00 p.m.*
*5 p.m. if Fri. before holiday
The following authorization must be signed before a Notary Public by the individual named on the
birth record (if 18 years of age or older) or the parent of the individual named on the birth record. The
appointed representative must also complete a Request for Birth Record and present proper
identification to obtain the record.
(Please print information and sign below)
I,_________________________________________, being duly sworn, on
oath depose and state as follows: That I am (check one):
o The individual named on the birth record, and I am 18 years of age or older.
o The Parent or Legal Guardian of the individual named on the birth record.
(Circle relationship)
I hereby appoint__________________________________________, (must be 18 yrs. or older) as
my legal representative for the purpose of obtaining the certified records of those named below:
Last Name First Name Date of Birth Place of Birth
_______________ _______________ ______________ ___________________
_______________ _______________ ______________ ___________________
Your Name: ___________________________________________________
Address: ______________________________________________________
City: _____________________________ State _________ Zip: __________
Signature: _____________________________________________________
Signed and sworn (or affirmed) to before me on this
_______________ day of ______________________,_________________, by
_____________________________________________________________________.
(Print name of person who affirmed and signed in the presence of the notary)
_____________________________________
Notary Public Signature (Place seal to the right)
Fraudulent use of any vital record is a Class 4 felony punishable by imprisonment of up to 3 years and a
fine of $10,000 or both.
AUTHORIZATION FOR RELEASE OF BIRTH RECORDS
Rev 12/2018
Robin M. O'Connor
Lake County Clerk
LakeCountyClerk.info
