NOTE: Birth Certificates are confidential records and copies can only be issued to a person entitled to receive them. The application must indicate
the requestor’s relationship to the person listed on the record and indicate the intended use of the document. For additional information please see
reverse side or visit our website at www.dph.illinois.gov/topics-services/birth-death-other-records.
VR 180 (Rev. 10/18) Printed by Authority of the State of Illinois P.O.#1419166 10M 10/18 IOCI 19-303
State of Illinois
Illinois Department of Public Health
Application for Illinois Birth Record
Birth Certificate - Long Form
Accepted for all legal use, passport and other governmental agencies
(contains the most available information)
$15.00 first copy $2.00 each additional copy
Amount enclosed $__________ for ________ total copies
Birth Certificate - Short Form
Basic birth record information, may not be accepted by all
governmental agencies
$10.00 first copy $2.00 each additional copy
Amount enclosed $__________ for ________ total copies
Foreign Birth / Administrative Foreign Birth Record
Birth record of adopted person born outside of the United States
who were re-adopted in Illinois
$5.00 each copy
Amount enclosed $__________ for ________ total copies
Genealogical
Uncertified records for a birth 75 years and older
(not for legal use)
$10.00 first copy $2.00 each additional copy
Amount enclosed $__________ for ________ total copies
DO NOT SEND CASH Make check or money order payable to ILLINOIS DEPARTMENT OF PUBLIC HEALTH (IDPH).
For records prior to 1916, contact the County Clerk in the County where the birth took place
BLANK SPACE FOR OFFICE USE BIRTH CERTIFICATE NUMBER IF KNOWN (Not Required)
FULL NAME ON BIRTH RECORD (First, Middle, Last) As listed on Birth Record
DATE OF ILLINOIS BIRTH (Month, Day, Year) PLACE OF ILLINOIS BIRTH (City and or County) SEX
MOTHER / CO-PARENT’S NAME (Maiden Name Before First Marriage Required) As listed on Birth Record
FATHER / CO-PARENT’S NAME As listed on Birth Record
NAME OF INDIVIDUAL REQUESTING COPIES: REQUESTER RELATIONSHIP (Mother, Father, Legal Guardian etc.)
REQUESTER ADDRESS CITY STATE ZIP CODE
INTENDED USE REQUESTER PHONE NUMBER REQUESTER EMAIL ADDRESS
MAIL TO ADDRESS IF DIFFERENT THAN ABOVE CITY STATE ZIP CODE
SIGNATURE REQUIRED DATE
Complete Form IN FULL, Sign, Include Copy of Identification & Proper Fee
MAIL TO: IDPH Vital Records, 925 E. Ridgely Avenue, Springfield, IL 62702-2737
For additional information - www.dph.illinois.gov/topics-services/birth-death-other-records
IF THE BIRTH DID NOT OCCUR IN ILLINOIS YOU MUST CONTACT THE STATE WHERE THE BIRTH TOOK PLACE
IDENTIFICATION REQUIREMENTS
In order to process your request through this office we require identification to be provided
A photo copy of a NON-EXPIRED, GOVERNMENT ISSUED PHOTO IDENTIFICATION. Such as a Driver’s License,
Passport, FOID card, Active Duty Military ID, Veterans Administration Issued Photo Medical Card, or a Federally issued
Tribal ID card. ALL identification MUST have a photo, identifying information such as name, date of birth and an issue and
expiration date. If any information is contained on both sides of the ID, ensure a copy of both sides is made.
If your ID has expired and has an extension sticker, ensure a copy of the sticker is also made.
If your ID has expired LESS THAN 6 MONTHS, please include one additional document showing your name and current
address created within the last 6 months. Examples include legal mail such as a bill or financial statement sent to your
current legal address.
If your ID has expired MORE THAN 6 MONTHS or you DO NOT HAVE VALID ID, you will be required to submit TWO
forms of documentation with your name and current legal address listed. Documentation in lieu of an ID must be dated
within the last 6 months.
First Item – You must provide one or more of the following; Medical Card, Auto Insurance Card, Voter’s Registration Card,
Paycheck Stub with Imprinted FULL information, Bank, Financial, or a Credit Card Statement.
Second Item - You must provide a piece of current mail you have received showing your full name and current legal
mailing address. Examples include current utility bill, phone bill or bill for services you have received. You may submit
multiple pieces of mail however ensure they are from different Agencies or businesses.
If you are currently incarcerated in a State or Federal facility, you will need to submit a dated copy of your prison intake or
offender summary sheet containing your photo, name, date of birth and facility information.
If you have been RELEASED from prison WITHIN THE LAST 6 MONTHS, you may provide a copy of your release papers
along with a copy of your prison photo ID. Please note that the release papers MUST show an address that you have
been released to that matches the address you are using with this office.
If you are a State, Federal Agency or a Hospital, you may submit a copy of your work photo ID badge. The badge MUST
have a photo, name, name of the Agency and an issue and expiration date along with any supportive paperwork required
for the request. If your work ID does not meet the requirements, a copy of your government issued photo ID, Drivers
License or Passport must also be included.
SOCIAL SECURITY CARDS ARE NOT ACCEPTABLE
ELIGIBILITY TO OBTAIN AN ILLINOIS BIRTH RECORD
Before a request for a copy of a birth record can be considered you must specify your eligibility to obtain it.
ILCS410/535/25(4) states that copies of birth records may only be issued upon; The order of a court of competent
jurisdiction; The specific written request by the person listed on the record if of legal age (18 or older) or by a parent or
other legal representative* of the person to whom the record of birth relates; The specific written request by a Department
of State, Municipal Corporation or the Federal Government
*77 Illinois AdmCode 500.10 refers to “Legal Representative” as either an attorney acting on behalf of a person named on
the birth record; An agent authorized by power of attorney; A Court-appointed representative; An agent with written,
notarized authorization from a person named on the birth record for the purpose of obtaining a copy for that person; Any
other agent, approved by the State Registrar as a legal representative.
NOTE: Any person who, willfully and knowingly uses or attempts to use, or furnishes to another for use, for any purpose
of deception, any certificate, record, report, certification or certified copy thereof so made, altered, amended, or mutilated;
or, Any person who with the intention to deceive, willfully uses or attempts to use any certification or certified copy of a
record of birth knowing that such certification or certified copy was issued upon a record that is false in whole or in part or
that relates to the birth of another person is guilty of a Class 4 felony in the State of Illinois (ILCS 410/535/27 (f)).
Illinois Law (ILCS 410/535/25 (1)) requires advanced payment for the search of death record files.
*Fees are subject to current Illinois Statute and administrative policy and may be non-refundable.*
State of Illinois
Illinois Department of Public Health