Must be typewritten-Do not fold All facts must be given as of time of birth OHIO CORRECTION OF BIRTH RECORD Application, Finding and Order for Correction of Birth Record Case No.____________________Doc._________________Page___________________ In the Probate Court of _____________________________County, on the __________________________ day of _____________________, 20_____, appeared_______________________________________ Name of Registrant praying that the facts of birth be established in accordance with section 3705.15 of the revised code, as follows: Child Full Name (at time of birth) Exact Place of Birth Social Security No. Date of Birth(mm/dd/yyyy) Male Age of Father (at time of birth) Birthplace of Father Maiden name of Mother Mother Father Name of Father Female Age of Mother (at time of birth) Birthplace of Mother Item(s) 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______________________ 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 registration of said birth. __________________________________________ Registrant or 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 of applicant be registered in accordance with the facts hereinabove set forth; and that a summary finding and order of the court, duly certified, 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. __________________________________________ Probate Judge (SEAL) By________________________________________ Deputy Clerk 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 that I was the physician in attendance at the birth of________________________________________________, the applicant and that the facts stated herein (Name of applicant at birth) are true as he verily believes. ____________________________________ Attending Physician ___________________________________________ (Address) Sworn to before me and signed in my presence 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, relatives or non-relatives, having personal knowledge of the facts. State of Ohio, __________________________________________________________Affidavit The undersigned, being first duly sworn, deposes and says that___he is_______years of age, that ___he has read the application and that____he 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 verily believes. ____________________________________ (Signature of Affiant) ____________________________________ (Address) Sworn to before me and signed in my presence this_______day of _______________________, 20______. ___________________________________________ ___________________________________________ (Official Title) State of Ohio, __________________________________________________________Affidavit The undersigned, being first duly sworn, deposes and says that___he is_______years of age, that ___he has read the application and that____he 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 verily believes. ____________________________________ (Signature of Affiant) ____________________________________ (Address) Sworn to before me and signed in my presence this_______day of _______________________, 20______. ___________________________________________ ___________________________________________ (Official Title) Reset American LegalNet, Inc. www.FormsWorkFlow.com