18 N. County St., Room 101
Waukegan Illinois 60085
847-377-2411
LakeCountyClerk.info
Robin M. O’Connor
Lake County Clerk
$10.00 for a certified copy.
$4.00 for each additional certified copy of same record issued at same time.
$4.00 for a non-certified copy stamped “for genealogical purposes”
(available
only if the record is at least 75 years old.)
Individual Named on Birth Record (please print information and sign below):
______________________________________________________________
First Middle Last Name (at birth)
Date of Birth: ___________________________ Quantity: ______________
Place of Birth (City or Village): ___________________________________
Father/Co-Parent’s Maiden Name:
______________________________________________________________
First Middle Last (prior to first marriage/civil union)
Mother/Co-Parent’s Maiden Name:
____________________________________________________________________
First Middle Last (prior to first marriage/civil union)
Intended use: _________________________________________________
Person requesting record
(check appropriate box):
Individual named on record (you must be 18 years or older
)
Parent, Legal Guardian, or Legal Representative (circle relationship)
Genealogist (reco
rd must be at least 75 years old)
Your Name: ___________________________________________________
Current Address: ______________________________________________
City: ___________________________ State: _________ Zip: ___________
Phone: __________________ E-mail: _____________________________
I do hereby attest that as the individual requesting this record, I am legally entitled to a certified copy
or a non-certified copy (if applicable) of this record either personally being of age; as a parent,
guardian, legal representative, or agent of the person whose record I am requesting; as having a
qualified genealogical or property right interest; or because I am otherwise entitled to the record
according to the Illinois Compiled Statutes (410 ILCS 535/25). I acknowledge that an individual who
commits fraudulent use of a vital record is guilty of a Class 4 Felony, punishable by up to three years
imprisonment.
Signature: ___________________________________________
Acceptable Forms of Identification
Must provide one (1) valid U.S. identification document
• Driver’s license
• State identification card
• Passport (with signature)
• Military identification card (with signature)
If you do not have any of the above forms of identification, you must
present two (2) pieces of the following documentation:
• Social Security Card with signature
• Certified copy of voter registration record
• Employee ID Card with photo and signature
• School ID Card with photo and signature
• Township ID Card with signature
• Certified copy of a birth certificate
C
ert
ified English translation required for foreign certificates
• U.S. original naturalization papers
• A valid foreign passport
• A valid U.S. resident alien card
• A valid consulate identification car
d
• A valid U.S. visa with photo and signature
Affidavits or expired documents are not acceptable.
Requesting a record by mail:
1. Complete all information on the request form.
2. Sign on the signature line.
3. Make legible photocopy of your identification (both sides.)
4. Write check or money order payable to “Lake County Clerk.”
5. Include a large, self-addr
ess
ed, stamped envelope.
6.
Mail all items to: Lake County Clerk
Attn: Vital Records
18 N. County St., Room 101
Waukegan, IL 60085
BIRTH RECORD REQUEST
Valid identification required. See list to the right.
Rev 3/2020
OFFICE USE ONLY
