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 FATHER:

STATE OF

SS

COUNTY OF

being duly sworn, deposes and says:

(Name of person making affidavit)

FIRST: that he is

years of age and resides at

Street

in the City of

, State of

SECOND: that he is the natural father of

a (fe)male child,

and that said child was born on the

day of

, 19

in the City of

, County of

, State of Illinois, and in

Hospital, to

(Maiden name of mother)

THIRD: that he was married to the said mother on the

day of

, 19

 at

, State of

(City, town or county)

FOURTH: that he 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 FATHER:

Color or race

Place of birth

Date of birth

Occupation when child was born

Social Security Number

Signature of father

Subscribed and sworn to before me this

day of

, 19

Notary Public

VR-172 (1991r)

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