Fillable Birth Record Request Form A3 %28 Fillable%29

Fill Online, Printable, Fillable, Blank Birth Record Request Form A3 %28 Fillable%29 Form

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Birth Record Request Form A3 %28 Fillable%29

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The Birth Record Request Form A3 %28 Fillable%29 form is 2 pages long and contains:

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Page 1 of 2 (Please Note: BOTH pages MUST be completed and submitted to qualify for and receive a free birth certificate)
IF REQUESTING BY MAIL, PLEASE DO THE FOLLOWING:
Mail this completed form to: Bureau of Vital Records, P.O. Box 641070,
Chicago, Illinois 60664-1070, with 1) A photocopy of your photo id (e.g.
driver's license, or state issued) & 2) A self-addressed stamped evenlope.
IF REQUESTING IN-PERSON, PLEASE DO THE FOLLOWING
Visit our main office at: 50 W. Washington St. (in the Pedway underneath
the Daley Center, CL-25), or visit one of our FIVE suburban offices.
For hours/locations call 312.603.7790 or visit cookcountyclerk.com/vitals
Please indicate below how you would like to receive the requested Birth Certificate. If requesting the document be mailed please
include a photocopy of some form of photo identification, and a self-addressed stamped envelope (to expedite the returned record).
I would like the requested Birth Certificate to be:
Mailed to me at the above address
Filled while I wait
Filled and ready when I return later
Mailing Address of the Submitter (Street Number & Name) Above
Mailing City, Town or Village of Submitter Above
Mailing State and Zip Code of Submitter Above
Submitter Phone Number Above
Submitter's Relationship to the Person/Birth Certificate Requested
SPECIAL NOTICE TO THE SUBMITTER OF THIS BIRTH RECORD REQUEST FORM
Pursuant to §410 ILCS 535/25(4)(b), "a certified copy of a birth record is ONLY available to persons with a direct and tangible interest in the record, such
as one's self, parent, guardian or legal representative. Anyone who willfully and knowingly uses or attempts to use any certificate and/or certification for
the purposes of deception is guilty of a Class 4 Felony, as outlined in §410 ILCS 535/27(c)(f), which is punishable by up to three years in prison.
First Name of Submitter Above
Last Name of Submitter Above
Date of Birth (Include Month, Day & Year) Above
Place of Birth (City, Town or Village in Cook County) Above
First Name of Biological/Adopted Mother (At Birth) Above
Last Name (Maiden) of Biological/Adopted Mother (At Birth) Above
First Name of Biological/Adopted Father (At Birth) Above [Optional]
Last Name of Biological/Adopted Father (At Birth) Above [Optional]
Resident of Domestic Abuse Shelter
First Name (At Birth) Above
Middle Name (At Birth) Above
Last Name (At Birth) Above
KAREN A. YARBROUGH I COOK COUNTY CLERK'S OFFICE
VITAL RECORDS DIVISION
P.O. BOX 641070, CHICAGO, ILLINOIS 60664-1070
Telephone: 312.603.7788 I Fax: 312.603.4899 I Web Address: cookcountyclerk.com
BIRTH RECORD REQUEST FORM - A3
agent or agency to confirm that the requestor is ELIGIBLE for a free birth certificate, and MUST be submitted with the request.
PLEASE SELECT THE REQUESTOR'S STATUS AT THE TIME OF THIS REQUEST
A certified copy of a birth record is available at NO COST to persons born in Cook County who are verified as one of the following:
A) Homeless; B) Residents of shelters for victims of Domestic Abuse/Violence; C) A person released within the last 90 days from
or detainee who will be released within the next 90 days from IDOC or CCDOC. A status certification MUST be completed by an
the Illinois Department of Corrections (IDOC) or the Cook County Department of Corrections (CCDOC), and/or D) A current inmate
Released from IDOC/CCDOC w/n past 90 days
Incarcerated
PLEASE PRINT LEGIBLY TO ENSURE ACCURATE FULFILLMENT OF YOUR REQUEST
KAREN A. YARBROUGH I COOK COUNTY CLERK'S OFFICE
VITAL RECORDS DIVISION
P.O. BOX 641070, CHICAGO, ILLINOIS 60664-1070
Telephone: 312.603.7788 I Fax: 312.603.4899 I Web Address: cookcountyclerk.com
STATUS CERTIFICATION - MUST BE COMPLETE BY VERIFYING AGENT
To the Honorable Clerk of Cook County, please accept this Status Certification to verify that the above listed individual should qualify
for a FREE Birth Certificate because either the individual her or himself, or the child listed on this form currently belongs to one (or more)
of the following required categories, as set forth in Illinois & Cook County law: (please select ALL which apply)
Homeless - Must be Verified by an Agent or Agency
Survivor of Domestic Abuse - Currently Living in Shelter
This Status Certification is provided for the listed Agent or Agency to indicate and confirm the named individual's status at the
time of the included Birth Record application. This Status Certification MUST accompany the Birth Record application for any
Free Birth Records requests. Finally, this Status Certification entitles the requestor to a single Free Birth Record.
Date Certification Submitted Above
First Name of Birth Record Requestor Above
Last Name of Birth Record Requestor Above
Homeless Service Agency receiving Federal, State, County, or Municipal funding to provide those or similar services.
Sanctioned by a local continuum of care
Attorney licensed to practice in the State of Illinois (must include Attorney Registration Disciplinary Commission Information below)
Released from IDOC or CCDOC in past 90 days
Incarcerated in IDOC or CCDOC but released in 90 days
My relationship to the above-listed individual, who is now requesting a Free Birth Record is as follows: (please select ALL which apply)
Staff Member who services a Human Service Agency or Government Office that assists the recently or presently Incarcerated
Other please explain: ________________________________________________________________________________________
Liaison for the Homeless with a Public School system, OR, Social Worker who works with the Homeless
Human Services Provider funded by the State of Illinois to service the Homeless or Runaway youth individuals w/ mental illness or addictions
Staff Member who works with a Domestic Violence Shelter
Mailing Address with Street Number, Name, City, State & Zip Code
Federal Tax Identification Number or ARDC Number for Attorney
Email Address of Verifying Agent
VERIFYING AGENCY/AGENT INFORMATION BELOW:
Verifying Agency or Agent Name Above
Telephone Number of Verifying Agency/Agent Above
Printed Name of Verifying Agent/Agency Employee
Signature of Verifying Agent/Agency Employee
Date Signed by Agent/Agency Employee
Page 2 of 2 (Please Note: BOTH pages MUST be completed and submitted to qualify for and receive a free birth certificate)
I, the below listed verifier, do now swear or affirm that I am a representative of the above-referenced Agency, and that the
above-listed applicant is in fact an individual who meets the requirements for this waiver application for a Free Birth Record.
I also understand that providing false information on this form could subject me to prosecution for perjury as outlined in Illinois law.
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Birth Record Request Form A3 %28 Fillable%29

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Completed 16 July 2020

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