You must use this form, along with the required identification materials (see below) to receive birth certificates by mail from the Winnebago County Clerk. Print out the request form and send it along with $15.00 (1st copy) + (if needed) $4.00 for a second copy - check or money order and proper identification - to the address on the form.
Cut along dotted lines
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JOHN SCHOU, County Clerk |
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Winnebago County Administration Bldg. |
404 Elm Street, Rm. 103 |
Rockford, IL 61101 |
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BIRTH CERTIFICATE REQUESTS |
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No.of Copies _________ **PLEASE SEND COPY OF ACTUAL RECORD** |
Please Print Information |
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Name____________________________________________________ |
First Middle Last |
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Date of Birth _________________Hospital Name ___________ |
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Name of Father__________________________________________ |
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Maiden Name of Mother___________________________________ |
First Middle Last |
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I, the undersigned, do hereby certify that as the person |
whose record is sought, or as the parent, guardian, or |
legal representative of the person, am legally entitled |
according to the Illinois Compiled Statutes |
(410 ILCS 535/25). |
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______________________ ________________________________ |
Print Your Name Your Signature |
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______________________ ________________________________ |
Address Relationship to Person on Document |
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______________________ ________________________________ |
City Phone |
********************************************************** |
THIS AREA FOR MAIL-IN ONLY |
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Mail to: Name ___________________________________________ |
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Address___________________________________________________ |
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City_________________________State_________Zip____________ |
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Date Mailed:_______________Deputy:________________________ |
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Acceptable
Identification to Receive Records
- For Mail In Requests, a Photocopy of One of the following must be included.
- All documents must be current and valid.
- The Winnebago County Clerk's Office Reserves the right to request additional identification to receive records.
* One of the following......
- Illinois Driver's License
- Illinois State Identification Card
- Out-of-State Drivers License or State ID Card
- U.S. Government Driver's License
- Naturalization Certificate
- U.S. Military Identification Card
- U.S. Immigration Card
- Selective Service Card
- Illinois Public Aid ID Card with Medical Card
* or two of the following......
- Social Security Card or Print-out
- Voter Registration Card
- W-2 Form
- Bank Statement (within 90 days)
- Utility bill (within 60 days)
- Vehicle Registration Card
- Active Insurance Policy (at least one year old)
- Checkbook or Savings book (showing name and address)
- Employee Identification Card
- Traffic Ticket
- Resident Alien Card
- School Identification Card
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Katy Hestand
County Coordinator
© Copyright 2005. All Rights Reserved. All materials contained on these pages are furnished for the free use of those individuals researching their family origins. ANY COMMERCIAL USE, PUBLICATION, OR POSTING OF THIS MATERIAL ON ANY OTHER WEBSITE, WITHOUT THE WRITTEN CONSENT OF THE CO-COORDINATOR/ AUTHOR/SUBMITTER OF THE MATERIAL/PAGE, IS PROHIBITED. All images used on these pages were obtained from sources permitting free distribution, or generated by the author, and are subject to the same restrictions/permissions. All persons contributing material for posting on these pages do so in recognition of their free, non-commercial distribution, and furthermore, are responsible to assure that no copyright is violated by their submission.
This page created by Cecelia Yeruski for the
ILGenWeb Project.
Last updated: Monday, 18-Apr-2005 10:02:56 MDT