STATE OF ILLINOIS

DEPARTMENT OF PUBLIC HEALTH

DIVISION OF VITAL RECORDS

SPRINGFIELD 62702-5097

NOTE:  A CERTIFIED COPY OF YOUR MARRIAGE RECORD MUST ACCOMPANY THE COMPLETED AFFIDAVITS. AFFIDAVITS MUST BE SIGNED BEFORE A NOTARY PUBLIC OR THEY WILL NOT BE ACCEPTED.

AFFIDAVIT BY MOTHER

STATE OF

SS

COUNTY OF

being duly sworn, deposes and says:

(Name of person making affidavit)

FIRST: that she is

years of age and resides at

Street

in the City of

, State of

SECOND: that she is the mother of

a (fe)male child

and that said child was born on

day of

, 19

, in the City of

,

County of

, State of Illinois, and in

Hospital,

and at that time she age her name as

for the purpose of recording its birth.

THIRD: that the natural father of said child is

and that she was married to said father on the

day of

, 19

at

, State of

.

(City, town or county)

FOURTH: that she now requests that a certificate of birth be prepared and filed showing said child to be the

legitimate child of

and the child's new name as

CHILD'S NAME

FIRST

MIDDLE

LAST

FIFTH:  that the following are the PERSONAL PARTICULARS CONCERNING THE MOTHER:

Mother's maiden name:

Date of birth

Color or race

Occupation when child was born

Place of birth

Social Security Number

Signature of Mother

Subscribed and sworn to before me this

day of

, 19

.

Notary Public

VR-171 (1991r)

ILLINOIS DEPARTMENT OF PUBLIC HEALTH – DIVISION OF VITAL RECORDS – SPRINGFIELD 62702-5097