PROBATE COURT OF SHELBY COUNTY, OHIO IN THE MATTER OF CASE NO. APPLICATION FOR CORRECTION OF BIRTH RECORD Applicant prays for an order of the Court to correct the birth record of [select one]: applicant; the minor child of the applicant whose name is , in accordance with R.C. 3705.15. Applicant has attached a copy of the original birth record and states that the following item(s) in the original birth record (is)(are) incorrect: ITEMS 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 The applicant 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 correction of said birth record. Signature of Applicant Printed or Typed Name of Applicant Address Phone Number [include area code] Sworn to before me and subscribed in my presence this Notary Public H.C. FORM 623.00 - APPLICATION FOR CORRECTION OF BIRTH RECORD day of , . American LegalNet, Inc. www.FormsWorkFlow.com 02/10/03