IN THE PROBATE COURT OF MAHONING COUNTY, OHIO JUDGE MARK BELINKY REGISTRATION OF BIRTH APPLICATION, FINDING AND ORDER FOR REGISTRATION OF BIRTH [R.C. §3705.15] CASE NO. _______________________ _____________________________, the Applicant, prays that the facts of birth be established in accordance with section 3705.15 of the Revised Code, as follows: Applicant’s Full Name (at time of birth) _____________________________________________ [Social Security No.__________________] Place of Birth _________________________________________________________ Date of Birth ____________________ Male Female (City, State, Hospital, Home Address) Father’s Full Name ______________________________________________________ Age of Father (at time of birth) ________________ Birthplace of Father _________________________________________________________________________________________________ Mother’s Maiden Name ____________________________________________________ Age of Mother (at time of birth) ______________ Birthplace of Mother ________________________________________________________________________________________________ The following evidence was presented to support the above facts and the parentage of the registrant, to wit: Document or name of Witness Date or Place of Birth record Date of Father’s Name Mother’s Maiden Name Birth 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 Area Code/Phone Sworn to before me and signed in my presence by the applicant or registrant aforesaid this _________day of _____________, 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 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. ______________________________________________________ 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 Revised 01-15-08 American LegalNet, Inc. www.FormsWorkflow.com CASE NO. ___________________ The State of ________, County of __________________________: Affidavit of Physician 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. _________________________ Signature of Attending Physician _______________________________ Full Address ___________________________________ City, State, Zip Area Code/Phone 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 ______________________: Affidavit of __________________________________ ______________________________________ I, ___________________________________________ (Age_________ Years), do hereby certify that I have personal knowledge of the facts stated in the within application by virtue of ____________________________________________ and that the facts stated herein are true, as I verily believe. _________________________ _______________________________ Signature of Affiant Full Address ___________________________________ City, State, Zip Area Code/Phone Sworn to before me and signed in my presence this ______________ day of _________________________, 20________ . ____________________________________________ (SEAL) ____________________________________________ Notary Public The State of _______, County of ______________________: Affidavit of__________________________________ I, ___________________________________________ (Age_________ Years), do hereby certify that I have personal knowledge of the facts stated in the within application by virtue of ____________________________________________ and that the facts stated herein are true, as I verily believe. _________________________ _______________________________ Signature of Affiant Full Address ___________________________________ City, State, Zip Area Code/Phone Sworn to before me and signed in my presence this ______________ day of _________________________, 20________. ____________________________________________ (SEAL) ____________________________________________ Notary Public Revised 01-15-08 American LegalNet, Inc. www.FormsWorkflow.com