H.C. FORM 624.00 - APPLICATION FOR REGISTRATION OF BIRTH RECORD 07/01/18 PROBATE COURT OF HAMILTON COUNTY, OHIO RALPH WINKLER , JUDGE IN THE MATTER OF CASE NO. APPLICATION FOR REGISTRATION OF BIRTH RECORD Registrant prays that the fact of birth be established in accordance with R.C. 3705.15 as follows: Full Name of Child (at time of birth) Exact Place of Birth Date of Birth Male Female Name of Parent 1 Male Female Full Name of Parent 2 Male Female Age of Parent 1 (at time of this birth) Age of Parent 2 (at time of this birth) Birthplace of Parent 1 Birthplace of Parent 2 Last Name of Parent 1 Prior to First Marriage Last Name of Parent 2 Prior to First Marriage The registrant 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 registration of said birth. Signature of Registrant Printed or Typed Name of Registrant Address () P hone Number (include area code) Sworn to before me and subscribed in my presence this day of,. (SEAL) Notary Public American LegalNet, Inc. www.FormsWorkFlow.com