Form IOCI15-494 "Illinois Adoption Registry and Medical Information Exchange (Iarmie) Request for a Non-certified Copy of an Original Birth Certificate" - Illinois

What Is Form IOCI15-494?

This is a legal form that was released by the Illinois Department of Public Health - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Illinois Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form IOCI15-494 by clicking the link below or browse more documents and templates provided by the Illinois Department of Public Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form IOCI15-494 "Illinois Adoption Registry and Medical Information Exchange (Iarmie) Request for a Non-certified Copy of an Original Birth Certificate" - Illinois

Download PDF

Fill PDF online

Rate (4.8 / 5) 17 votes
State of Illinois
Illinois Department of Public Health
Illinois Adoption Registry and Medical Information Exchange (IARMIE)
REQUEST FOR A NON-CERTIFIED COPY OF AN ORIGINAL BIRTH CERTIFICATE
I, _______________________________________, hereby request a non-certified copy of
(check the appropriate option):
1. My original birth certificate. Notary NOT required.
2. The original birth certificate of my deceased adopted or surrendered parent or grandparent. Notary
required/below.
3. The original birth certificate of my deceased adopted or surrendered spouse. Notary required/below.
The adopted or surrendered person was born in the city of___________________________________,
county of__________________________ on _________________, _________ and the adopted name is:
Date
Year
First name ________________________________ Middle name _______________________________
Last name ___________________________________________
In the event that one or both of the birth parents have requested their identity not be released:
a. I wish to receive a non-certified copy of the original birth certificate from which identifying information
pertaining to my birth parents, who requested anonymity, has been redacted; or
b. I do not wish to receive a redacted copy of the original birth certificate.
NOTE:
Regardless of your selection above, all options require that you submit a copy of a non-expired, government issued photo
ID and a check or money order made to IDPH for $15.
If you selected option 2 or 3, you must be registered with the IARMIE as a surviving relative of the deceased adopted or
surrendered person. If you need to register, please contact the IARMIE at 877-323-5299.
________________________________________________
__________________
Signature
Date
Mailing address ________________________________________ City ______________________________
State ______________________ ZIP code ________________
Notary required if you checked option 2 or 3 above.
(Notary Public use only)
State of _______________________
County of _____________________________
I, a Notary Public, in and for the said county, in the state aforesaid, do hereby certify that
______________________________________ personally known to me to be the same person whose name is subscribed to the
foregoing request, appeared before me in person and acknowledged that (he or she) signed such request as (his or her) free and
voluntary act and that the statements in such request are true.
Given under my hand and notarial seal on _________________________________, ________
__________________________________________
Mail to: Illinois Department of Public Health, Division of Vital Records - IARMIE, 925 E. Ridgely Ave., Springfield, IL 62702-2737
IOCI 15-494
Printed by the Authority of the State of Illinois
State of Illinois
Illinois Department of Public Health
Illinois Adoption Registry and Medical Information Exchange (IARMIE)
REQUEST FOR A NON-CERTIFIED COPY OF AN ORIGINAL BIRTH CERTIFICATE
I, _______________________________________, hereby request a non-certified copy of
(check the appropriate option):
1. My original birth certificate. Notary NOT required.
2. The original birth certificate of my deceased adopted or surrendered parent or grandparent. Notary
required/below.
3. The original birth certificate of my deceased adopted or surrendered spouse. Notary required/below.
The adopted or surrendered person was born in the city of___________________________________,
county of__________________________ on _________________, _________ and the adopted name is:
Date
Year
First name ________________________________ Middle name _______________________________
Last name ___________________________________________
In the event that one or both of the birth parents have requested their identity not be released:
a. I wish to receive a non-certified copy of the original birth certificate from which identifying information
pertaining to my birth parents, who requested anonymity, has been redacted; or
b. I do not wish to receive a redacted copy of the original birth certificate.
NOTE:
Regardless of your selection above, all options require that you submit a copy of a non-expired, government issued photo
ID and a check or money order made to IDPH for $15.
If you selected option 2 or 3, you must be registered with the IARMIE as a surviving relative of the deceased adopted or
surrendered person. If you need to register, please contact the IARMIE at 877-323-5299.
________________________________________________
__________________
Signature
Date
Mailing address ________________________________________ City ______________________________
State ______________________ ZIP code ________________
Notary required if you checked option 2 or 3 above.
(Notary Public use only)
State of _______________________
County of _____________________________
I, a Notary Public, in and for the said county, in the state aforesaid, do hereby certify that
______________________________________ personally known to me to be the same person whose name is subscribed to the
foregoing request, appeared before me in person and acknowledged that (he or she) signed such request as (his or her) free and
voluntary act and that the statements in such request are true.
Given under my hand and notarial seal on _________________________________, ________
__________________________________________
Mail to: Illinois Department of Public Health, Division of Vital Records - IARMIE, 925 E. Ridgely Ave., Springfield, IL 62702-2737
IOCI 15-494
Printed by the Authority of the State of Illinois