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 Parent's Name Place of Birth Date of Birth ITEMS TO BE CORRECTED OR ADDED 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 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. ________________________________________________ Probate Judge I hereby certify the above is a true copy of the application and entry in the foregoing matter. (SEAL) By____________________________________________ Magistrate, Judge or Deputy Clerk HEA 2783 (REV. 8/2015) American LegalNet, Inc. www.FormsWorkFlow.com 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 the he was the physician in attendance at the birth of ________________________________________ the applicant and that the facts stated herein are true as he/she verily believes. (Name of Applicant at Birth) ________________________________________________ (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 be secured, 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 ________________________________________ (state relationship, if any, or state facts showing personal knowledge) and that the 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 ________________________________________ (state relationship, if any, or state facts showing personal knowledge) and that the 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 (REV. 8/2015) American LegalNet, Inc. www.FormsWorkFlow.com