410 ILCS 535/25.7: Certification letter form.

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:.........................