Correction Of Birth Record Form

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CORRECTION OF BIRTH RECORD

Application, Finding and Order for Correction of Birth Record

Case Number_______________________

In the Probate Court of _____________________________County on the _____________day of _________________________, 20_____,

appeared ____________________________________________________praying that his/her birth record be corrected in accordance with Section

3705.15 of the revised code as followed:

Information recorded in this box should match information currently listed on the Birth Record.

Child’s Information

Full Name of Child

Date of Birth

Place of Birth (city and county)

Information of Parent(s) currently listed on the Birth Record

Parent’s Name

Place of Birth

Date of Birth

Place of Birth

Date of Birth

ITEMS TO BE CORRECTED OR ADDED

ITEM__________________READS AS_________________________________SHOULD READ________________________________

The undersigned being first duly sworn, says the facts stated in the foregoing Application are true as he/she verily believes and prays that the Court

order the registration of birth.

Registrant of Applicant

Address

Sworn to before me and signed in my presence by the applicant or registrant aforesaid this___________day of______________20___.

(SEAL)

__________________________________________________

Official Character

Journal Entry

The court on consideration of the aforesaid evidence submitted finds and orders that 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.

________________________________________________