Must be typewritten-Do not fold All facts must be given as of time of birth OHIO REGISTRATION OF BIRTH Application, Finding and Order for Registration of Birth 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) Social Security No. Exact Place of Birth Date of Birth(mm/dd/yyyy) Male Maiden name of Mother Mother Father Name of Father Female Age of Father (at time of birth) Birthplace of Father Age of Mother (at time of birth) Birthplace of Mother The following evidence is presented to the court to support the above facts of the place and date of birth and the parentage of the registrant to wit: Document or Name of Witness Date of Record Place of Birth Date of Record Father’s Name Mother’s Maiden Name 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 Probate Court, ______________________________________County, Ohio AFFIDAVIT OF PHYSICIAN In the Matter of (1)______________________________ of______________________________ The State of Ohio, _______________________________________________County: ss. I,____________________________________, do hereby certify that I was the physician in attendance at the birth of_________________________________________________, the applicant herein, and that the facts in the application are true, as I verily believe. ____________________________________ Attending Physician P.O. 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 affidavits of two persons, relatives or non-relatives, having personal knowledge of the facts or by clear and convincing documentary evidence or such other evidence as the court deems sufficient. State of Ohio, ____________________________________County: ss. AFFIDAVIT I, _______________________________________________________, (Age_________Years) do hereby certify that I have personal knowledge of the facts in the within application, and that the facts stated herein are true, as I verily believe._____________________________________________________ P.O. Address_______________________________________________ Sworn to before me and signed in my presence this_______day of _______________________, 20______. ___________________________________________ ___________________________________________ (Official Title) State of Ohio, ____________________________________County: ss. AFFIDAVIT I, _______________________________________________________, (Age_________Years) do hereby certify that I have personal knowledge of the facts in the within application, and that the facts stated herein are true, as I verily believe._____________________________________________________ P.O. Address_______________________________________________ Sworn to before me and signed in my presence this_______day of _______________________, 20______. ___________________________________________ ___________________________________________ (Official Title) American LegalNet, Inc. www.FormsWorkFlow.com