§ 25.7 — Certification letter form

Illinois § 25.7

• Jurisdiction: Illinois
• Topic: HEALTH AND SAFETY
• Ch. 410: PUBLIC HEALTH
• Act 410 ILCS 535/: Vital Records Act.

Text

In order to seek a waiver of the fee for a copy of a vital record, the person seeking the record must provide the following certification letter: Certification Letter for Domestic Violence Waiver for Illinois Vital Records Full Name of Applicant:............................... Date of Birth:........................................ I,........................, certify, to the best of my knowledge and belief, that on the date listed below, the above named individual is a victim or child of a victim of domestic violence, as defined by Section 103 of the Illinois Domestic Violence Act of 1986 (750 ILCS 60/103), who is currently fleeing a dangerous living situation. I provide this certification in my capacity as (check one below): ( ) an advocate at a family violence center who assisted the victim; ( ) a licensed medical care or mental health provider; ( ) the director of an emergency shelter or transitional housing; or ( ) the director of a transitional living program. Signature:................. Date:........................ Title:..................... Employer:.................... Email:..................... Phone:....................... Address:................... City:........................ State:..................... Zip:.........................

Legislative History

(Source: P.A. 103-170, eff. 1-1-24; 103-605, eff. 7-1-24.)