IN THE PROBATE COURT OF MAHONING COUNTY, OHIO JUDGE MARK BELINKY CORRECTION OF BIRTH RECORD APPLICATION, FINDING AND ORDER FOR CORRECTION OF BIRTH RECORD [R.C. §3705.15; Loc. R. 75.6 (A)] CASE NO. the Applicant, prays that his/her birth record be corrected in accordance with section 3705.15 of the Ohio Revised Code, as follows: Applicant's Full Name (at time of birth) Place of Birth [Social Security No. Date of Birth (City, State, Hospital, Home Address) Applicant's sex at the time of his/her birth: Male Female Age of Father (at time of birth) Father’s Full Name Birthplace of Father Mother’s Maiden Name 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 (Supplement, if necessary, and attach). Wherefore the undersigned applicant, being first duly sworn, says that the facts stated in the foregoing Application are true as he/she verily believes. Applicant’s Signature Full Address City, State, Zip Sworn to before me and signed in my presence by the applicant aforesaid this day of Area Code/Phone , 20 . (SEAL) Notary Public JUDGMENT ENTRY The Court, upon consideration of the aforesaid and the evidence submitted, finds that the applicant personally appeared and was examined, that notice of hearing was completed or was dispensed with and Orders that the birth record of applicant 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. Hon. Mark Belinky, Judge I hereby certify the above is a true copy of the application and entry in the foregoing matter. Hon. Mark Belinky, Judge (SEAL) By Deputy Clerk Form 75.6 (A) M.C. Revised 09-11-02 American LegalNet, Inc. www.FormsWorkflow.com The State of : , County of I, Affidavit of Physician , do hereby certify that I was the physician in attendance at the birth of (Typed or Printed Name) , the applicant herein, and that the facts in the application are true, as I verily believe. Signature of Attending Physician Address Sworn to before me and signed in my presence this day of . , 20 (SEAL) Notary Public NOTE: If the affidavit of the attending physician cannot be secured, the application must be supported by the following affidavits of two persons, relative or non-relative, having personal knowledge of the facts or by clear and convincing documentary evidence or such other evidence as the Court deems sufficient. The State of , County of : (Age I, Affidavit of Years), do hereby certify that I have personal knowledge of the facts stated (Typed or Printed Name) in the within application by virtue of and that the facts stated herein are true, as I verily believe. Signature of Affiant Address Sworn to before me and signed in my presence this day of , 20 . (SEAL) Notary Public The State of , County of : (Age I, Affidavit of Years), do hereby certify that I have personal knowledge of the facts stated (Typed or Printed Name) in the within application by virtue of Signature of Affiant Sworn to before me and signed in my presence this and that the facts stated herein are true, as I verily believe. Address day of , 20 . (SEAL) Notary Public Form 75.6 (A) M.C. Revised 09-11-02 American LegalNet, Inc. www.FormsWorkflow.com