Correction Of Birth Record

Must be typewritten Do not fold. All Facts must be given as ofTime of Birt h CORRECTION OF BIRTH RECORD Application, Finding and Order for Correction of Birth Record OHIO Case N o.___ ___ ____ __ Doc. ______ Page ______ In the Probate Court of _________________________________________ County, on the _________________________ day of ________________________, 20____, appeared ____________________________________________________ Name of Registrant praying that his/her birth record be corrected in accordance with Section 3705.15 of the revised code, as follows: Full Name (at time of birth) Social Security No. Exact Place of Birth Date of Birth Child U Male U Female Name of Father Maiden Name of Mother Age of Father a(t time of this birt) h Age of Mother (at time of this birth) Father Birthplace of Father Mother Birthplace of Mother Item(s) to be correctedr o added Item ______________ reads as ____________________________ should read _____________________________ Item ______________ reads as ____________________________ should read _____________________________ Item ______________ reads as ____________________________ should read _____________________________ Item ______________ reads as ____________________________ should read _____________________________ Item ______________ reads as ____________________________ should read _____________________________ The undersigned being first duly sworn, says that the facts stated in the foregoing Application are true as he/she verily believes and prays that the Court order the correction of said birth record. Registrant or Applicant Address Sworn to before me and signed in my presence by the applicant or registrant aforesaid this ______________ day ______________________of _____ _______ 20 _____. (((SSSEEEAAALLL))) Official Character Journal Entry The Court on consideration of the aforesaid evidence submitted finds and orders that said notice of hearing be dispensed with and the birth record of registrant be corrected in accordance with the facts hereinabove set forth; and that a certified copy of the order of the Court be forthwith transmitted to the Director of Health, at Columbus, Ohio, as provided by law. Judge Jack R. Puffenberger I hereby certify the above is a true copy of the application and entry in the foregoing matter. Judge Jack R. Puffenberger (((SSSEEEAAALLL))) By Deputy Clerk dpcs@- American LegalNet, Inc.American LegalNet, Inc.HEA 2783 (4/91) LCPC Form COBR Correction of Birth Record REV 2 /05 www.USCourtForms.comwww.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 Supporting Affidavits In the Matter of the Correction of Birth Record of State of Ohio, _______________________________________________________ Affidavit of Physician The undersigned, being first duly sworn, deposes and says that he/she was the physician in attendance at the birth of the applicant and that the facts (Name of applicant at birth) stated herein are true as he/she verily believes. (Attending Physician) (Address) Sworn to before me and signed in my presence by the said This _____________ day of ___________________, 20____. (Official Title) NOTE: If the affidavit of the attending physician cannot securebe d, the application must be supported by the following affidavit, relative or non-relative, having personal knowledge of the facts. State of Ohio, _______________________________________________ Affidavit The undersigned, being first duly sworn, deposes and says that he/she is _____ years of age, that he/she has read the application and that he/she has personal knowledge of the facts stated therein by reason of being and that the (State relationship, if any, or state facts showing personal knowledge) statements made in the application are true as he/she verily believes. (Signature of Affiant) (Address) Sworn to before me and signed in my presence by the said This _____________ day of ___________________, 20____. (Official Title) State of Ohio, ______________________________________________________ Affidavit The undersigned, being first duly sworn, deposes and says that he/she is _____ years of age, that he/she has read the application and that he/she has personal knowledge of the facts stated therein by reason of being and that the (State relationship, if any, or state facts showing personal knowledge) statements made in the application are true as he/she verily believes. (Signature of Affiant) (Address) Sworn to before me and signed in my presence by the said This _____________ day of ___________________, 20____. (Official Title) HEA 2783 (4/91) Page 2 of LCPC Form COBR Correction of Birth Record REV 2/05 American LegalNet, Inc.American LegalNet, Inc. www.USCourtForms.comwww.USCourtForms.com