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 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
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
PLEASE PRINT LEGIBLY TO ENSURE ACCURATE FULFILLMENT OF YOUR REQUEST