ILLINOIS DEPARTMENT OF PUBLIC HEALTH

Division Of Vital Records

925 East Ridgely Ave.
Springfield, IL 62702-2737

STATE OF ILLINOIS AFFIDAVIT AND CERTIFICATE OF CORRECTION

State of______________________________:

Birth
Stillbirth
Death

SS
County of ____________________________:

(Indicate the type of record.)

I, ________________________________________________________, being duly sworn, deposes and says

(name of person making the affidavit)

FIRST; the information below lists the particulars of the record in question
Name currently on record ___________________________________________________________________
Place of birth or death ____________________________________ Date of birth or death ______________
(facility, city and county)

(month, day and year)

SECOND; the following information is incorrect or missing and should be corrected as follows
Item to be corrected

Incorrect information

Correct information

______________________

_____________________________ _________________________________

______________________

_____________________________ _________________________________

______________________

_____________________________ _________________________________

______________________

_____________________________ _________________________________

______________________

_____________________________ _________________________________
(If additional room is needed, complete another affidavit.)

THIRD; that the applicants current address is

Street address including apartment, floor or suite number__________________________________________
City, state and ZIP code ____________________________________________________________________
Relationship _________________________ Signature ___________________________________________
(to person listed on record)

(of person completing the affidavit)

Subscribed and sworn to before me this __________ day of __________________________, 20 _______

________________________________________
(Notary Public)

DO NOT WRITE BELOW THIS LINE.

______________________________________________________ Date made ______________________
______________________________________________________ Date made ______________________
______________________________________________________ Date made ______________________
______________________________________________________ Date made ______________________
______________________________________________________ Date made ______________________
Accepted for filing on the _______ day of_________________ 20 _____ By _______________________
Title _______________________

ILLINOIS DEPARTMENT OF PUBLIC HEALTH

Division Of Vital Records
925 East Ridgely Ave.
Springfield, IL 62702-2737
217-782-6553

AFFIDAVIT AND CERTIFICATE OF CORRECTION

INSTRUCTIONS
This affidavit and certificate of correction must be completed before this office can amend a birth, stillborn or
death record. The only exceptions to this are in cases of a court ordered legal name change or when an
amendment must be made due to a voluntary acknowledgment of paternity.
1. Complete the state and county in which this form is being signed and notarized.
2. Indicate if this is a death, stillborn or birth record by circling the correct type of record.
3. Provide the information, as it presently appears, on the record.
4. Indicate what item is to be corrected (e.g., childs name, mothers date of birth, date of death, etc.)
5. List the incorrect information as it presently appears on the record.
6. List the way the information should appear on the record.
7. Provide your complete name, relationship to the person on the record in question and address.
8. Take this form to a notary public and sign it in his/her presence. Notary publics are available at most
banks, currency exchanges, post offices, etc.
9. The notary public will supply his/her address, date notarized, signature and notary seal or stamp. This
entire section must be completed, including the notary seal or stamp.
Once completed, submit the original form to the Division of Vital Records at the above address. If you
received this document from the division, return it in the self-addressed envelope provided.
A $15 fee is required before any amendments can be made to the record. This includes one certified copy of
the amended record. Additional certified copies are $2 each if ordered at the same time. Make check or
money order payable to Illinois Department of Public Health or IDPH.
If you have additional questions, please contact this office Monday, Wednesday or Friday between 8:30 a.m.
and 4 p.m.

PLEASE NOTE: Most corrections, changes or additions to records require additional supporting
documentation. Submitting this form does not guarantee completion of your request.

VR 400

Printed by Authority of the State of Illinois

P.O. #145068
20M
7/04