The Birth Record Request Form - Form A3 is the form Cook County Vital Records, part of the Office of the Cook County Clerk, uses to request a free certified Cook County birth certificate. It serves people born in Cook County who are verified as homeless, living in a shelter for victims of domestic abuse or violence, recently released from IDOC or CCDOC custody, or about to be released. Page 2 is a Status Certification that a verifying agent completes and that must go in with the request. On FillingPDF you can fill out the form online and download or print the completed PDF; the Clerk receives it only by mail or in person, as described below.
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What is A3?
Birth Record Request Form - Form A3 is the Cook County Clerk's Vital Records form for requesting a certified copy of a birth record at no cost, available to eligible people born in Cook County whose status a verifying agent confirms.
The form has two pages, and the Clerk states that both must be submitted to receive a birth certificate. Page 1 holds the birth record information (name at birth, date of birth, place of birth in Cook County, and the parents' names) and the requestor's information. Page 2 is the Status Certification, completed by an agent or agency that confirms the requestor is eligible for a free certificate.
The no-cost copy is open to people born in Cook County who are verified as one of four groups: homeless; residents of shelters for victims of domestic abuse or violence; released within the last 90 days from IDOC or CCDOC custody; or current inmates or detainees who will be released within the next 90 days.
The Clerk's birth and death records page describes the Office of the Cook County Clerk as the record keeper for births and deaths in Chicago and suburban Cook County. Requests that do not qualify for the free copy are not made on this form's no-cost basis; the Clerk's page lists a fee for standard birth certificates, so ask the Clerk for current amounts.
Under Illinois law, a certified copy is available only to a person with a "direct and tangible interest" in the record.
Who needs to file A3?
Use Form A3 if you were born in Cook County, need a certified copy of your birth record, and are verified as one of these:
- Homeless;
- a survivor of domestic abuse, living in a shelter for victims of domestic abuse or violence;
- an ex-offender released within the last 90 days from IDOC or CCDOC custody;
- a current detainee or inmate who will be released within the next 90 days by IDOC or CCDOC.
The Status Certification also covers a person whose children are in one of these situations, since it confirms eligibility because "they or their children" are currently in that status.
Illinois law, cited on the form as 410 ILCS 535/25 (4) (b), limits certified copies to people with a "direct and tangible interest" in the record, such as yourself (if you are 18 years old), a parent, a guardian or a legal representative. If you are requesting for a child, the form asks for your relationship to the child.
An agent or agency must verify your status. The form lists who may do so, among them homeless service agencies, Illinois-licensed attorneys, public school homeless liaisons or school social workers, certain State-funded human services providers, domestic violence shelter staff, and staff of agencies or government offices that assist the incarcerated or formerly incarcerated.
When to file A3
Submit Form A3 when you need a free certified copy of your Cook County birth record and your eligibility status is in effect. The 90-day windows on the form matter: you qualify as an ex-offender if you were released within the past 90 days, and as a current detainee or inmate if you will be released within the next 90 days.
The Status Certification on page 2 must be received by the Cook County Clerk's office at the time of application, so have the verifying agent complete it before you mail or deliver the request. Both pages must be submitted together. The form prints no other deadline or processing time; for questions, the Vital Records office lists tel 312.603.7788 and, for in-person information, (312) 603-7790.
Documents you need
- Page 2 of the form, the Status Certification, completed and signed by the verifying agent or agency; it must be received by the Clerk at the time of application.
- A photocopy of your photo identification (for example a driver's license or state issued identification), when you request by mail.
- A self-addressed stamped envelope, when you request by mail.
- A parole release form, as an alternative verification the Clerk's birth and death records page names for formerly incarcerated applicants, in place of the status certification.
How to fill out A3
Select your eligibility status
On page 1, select one: Homeless, Survivor of Domestic Abuse, Ex-offender or Current detainee/inmate. Choose the status that the verifying agent will certify on page 2.
Enter your name at birth
Under BIRTH RECORD INFORMATION, write the First Name, Middle Name and Last Name as they appeared at birth.
Enter date and place of birth
Write the date of birth as Month/Day/Year and the City or Village in Cook County where the birth took place.
Enter your parents' names
For Name of Parent 1, give first name and last name (maiden name); if adopted, enter the mother's name at the time of adoption. Name of Parent 2 is optional.
Complete the requestor information
Under REQUESTORS INFORMATION, print your name, then enter your telephone number, mailing address (street address, city, state, ZIP) and your relationship to the child, if applicable.
Sign the request
Sign in the Signature box. Only a person with a direct and tangible interest in the record, such as yourself (if 18), a parent, guardian or legal representative, may request a certified copy.
Have the verifying agent complete page 2
The agent enters the date, the individual's name and the status being certified, then selects one qualification (for example homeless service agency, attorney licensed in Illinois, or domestic violence shelter staff member).
Add the verifying agency's details
The agent enters the agency or organization telephone number, mailing address, and the Agency Federal Tax ID Number or Attorney Registration Number.
Sign the perjury statement
The agency employee prints their name, signs and dates the statement made under penalty of perjury that they represent the agency and the applicant resides at or receives services from it.
Review and download the completed PDF
Check that both pages are complete and signed, then download or print the completed PDF from FillingPDF. Add your photo ID photocopy and a self-addressed stamped envelope if mailing, as described under How to submit.
How to submit A3
The Clerk's form names two ways to obtain a birth record: by mail and in person.
- By mail: fill out the form and mail the request to Bureau of Vital Records, P.O. Box A3390, Chicago, IL 60690. Include both pages (with the completed Status Certification), a photocopy of your photo identification (for example a driver's license or state issued identification), and a self-addressed stamped envelope.
- In person: visit the Cook County Clerk's Office at 118 N. Clark St., Room 120, Chicago, or one of its three suburban offices. Call (312) 603-7790 or go to cookcountyclerk.com/vitals for locations and hours.
The Clerk's birth and death records page adds that free certificates are only available when submitted with verification from a parole release form or a status certification completed by an approved human services provider. FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Submitting only page 1; the form states that both pages must be submitted to receive a birth certificate.
- Sending the request without the Status Certification, or with one the Clerk does not receive at the time of application.
- Mailing the request without a photocopy of your photo identification or without a self-addressed stamped envelope.
- Having someone verify your status who is not one of the qualified verifier types listed on page 2.
- Leaving the verifier's Agency Federal Tax ID Number or Attorney Registration Number, signature or date off the certification.
- Selecting a status on page 1 that does not match the status the verifying agent certifies on page 2.
- Requesting a record without a "direct and tangible interest", such as yourself (if 18), a parent, a guardian or a legal representative.
- Entering a place of birth outside Cook County; the form asks for the city or village in Cook County.
- Using a certificate or certification to deceive; the form warns this is a Class 4 felony punishable up to three years in prison.
Frequently asked questions
What is Birth Record Request Form - Form A3?
Form A3 is the Cook County Clerk's Vital Records form for requesting a certified birth record at no cost. It has two pages: the request itself and a Status Certification completed by a verifying agent. Both pages must be submitted to receive a birth certificate.
Who qualifies for a free Cook County birth certificate?
People born in Cook County who are verified as homeless, residents of shelters for victims of domestic abuse or violence, released within the last 90 days from IDOC or CCDOC custody, or inmates or detainees to be released within the next 90 days.
How do I get a free Cook County birth certificate with Form A3?
Complete page 1, have an eligible verifying agent complete the Status Certification on page 2, then mail both pages to Bureau of Vital Records, P.O. Box A3390, Chicago, IL 60690, or bring them to the Clerk's office at 118 N. Clark St., Room 120, Chicago.
Who can verify my status on the Status Certification?
Page 2 lists them: a homeless service agency, an Illinois-licensed attorney, a public school homeless liaison or school social worker, a State-funded human services provider, domestic violence shelter staff, or staff of an agency or government office assisting the incarcerated or formerly incarcerated.
What do I include when I mail Form A3?
Include both pages, with the completed Status Certification, a photocopy of your photo identification such as a driver's license or state issued identification, and a self-addressed stamped envelope. Mail to Bureau of Vital Records, P.O. Box A3390, Chicago, IL 60690.
Who can request a certified copy of a birth record in Cook County?
Only a person with a "direct and tangible interest" in the record, such as yourself (if you are 18 years old), a parent, a guardian or a legal representative, under Illinois law 410 ILCS 535/25 (4) (b), as cited on the form.
Can I submit Form A3 in person?
Yes. Visit the Cook County Clerk's Office at 118 N. Clark St., Room 120, Chicago, or one of its three suburban offices. Call (312) 603-7790 or go to cookcountyclerk.com/vitals for locations and hours.
Can I fill out Form A3 online on FillingPDF?
You can fill out the PDF online on FillingPDF and download or print it. FillingPDF is independent, not connected to the Cook County Clerk, and does not submit the form; you mail it or deliver it in person.
What happens if I misuse a birth certificate?
The form warns that anyone who willfully and knowingly uses or attempts to use a certificate or certification for deception is guilty of a Class 4 felony under 410 ILCS 535/27 (c), (f), punishable up to three years in prison.
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