Illinois Statutes Chapter 410. Public Health § 535/25.7. Certification letter form

§ 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:

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.