IN THE PROBATE COURT OF MAHONING COUNTY, OHIO JUDGE MARK BELINKY IN THE MATTER OF THE REGISTRATION OF THE BIRTH OF: CORRECTION OF BIRTH RECORD: CASE NO.: ______________ OF/FOR: ________________________________ DEPOSITION BY COMMISSIONER* [Revised Code §3705.15 (B)] Deposition of _____________________________________________ witness/applicant, taken before me, ___________________, the duly appointed Commissioner herein, a ___________________________ for the County of _____________________, State of ________________________. Pursuant to the attached commission issued to me, I caused the witness/applicant to appear personally before me on ___________, 20_____ , at ______________________________________, and after being first duly cautioned and sworn [or affirmed] by me, answered the following interrogatories: 1. What is your full name? Answer _______________________________________________________________________________ 2. What was the full name of applicant at time of birth? (Give first, middle and surname) Answer _______________________________________________________________________________ 3. What was the exact place of birth of applicant? Answer _______________________________________________________________________________ 4. What was the month, day and year of applicant’s birth? Answer _______________________________________________________________________________ 5. What was the sex of the applicant at the time of his/her birth? [NOTE: For “Corrections,” you must obtain and attach a certified, exemplified or authenticated copy of the original certificate of birth for the applicant.] Answer _______________________________________________________________________________ 6. What was the full name of applicant’s father? Answer _______________________________________________________________________________ 7. What was the birth father’s age at the time of applicant’s birth? Answer _______________________________________________________________________________ 8. Where was the birth father born? (City, Town or county) - (State or foreign country) Answer _______________________________________________________________________________ 9. What was the full maiden name of applicant’s mother? Answer _______________________________________________________________________________ 10. What was the birth mother’s age at the time of applicant’s birth? Answer _______________________________________________________________________________ 11. Where was the birth mother born? (City, Town or county) - (State or foreign country) Answer _______________________________________________________________________________ Revised 01-15-08 American LegalNet, Inc. www.FormsWorkflow.com CASE NO.: ______________ 12. What documents, if any, do you submit as exhibits, and in what ways do they support the allegations of the application. [Certified copies of original or photostatic copies of the documents submitted should be attached and properly marked as exhibits.] Answer _______________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ____________________________________ Signature of Witness/Applicant ____________________________________ Typed or Printed name ____________________________________ Address __________________________________ City State Zip ____________________________________ Area Code/Phone CERTIFICATE OF COMMISSIONER I, ________________________________, certify that I am a ___________________ for the aforesaid State and County and was duly acting and qualified as the commissioner at the time of the taking of the attached deposition, and further certify that the foregoing deposition of __________________________ was taken before me at the time and place and for the purpose specified in the commission. I further certify that deponent was first duly sworn to testify truthfully; that the deposition was reduced to writing by me, in the presence of the deponent__________________________ and was subscribed by the deponent in my presence. I further certify that I am not a counsel or relative of the applicant, or witness, nor am I otherwise interested in the proceedings. [SEAL] Date:________________________ Commissioner’s Fees: $____________ Witness Fees $____________ Total $____________ _________________________________ Commissioner’s Signature _____________________________ Typed or Printed Name _________________________________ Address _________________________________ City State Zip ___________________________________ Area Code/Phone [*NOTE: A separate “Deposition” must be completed for each applicant/witness]. American LegalNet, Inc. www.FormsWorkflow.com Revised 01-15-08 American LegalNet, Inc. www.FormsWorkflow.com