Download Affidavit of inability to produce Birth Certificate

________________________________________________
NORTHERN KY COOPERATIVE EL PROGRAM
AFFIDAVIT
OF INABILITY TO PRODUCE BIRTH CERTIFICATE
I, ________________________, have enrolled ______________________
(Name of Person Enrolling Student)
(Name of Student)
in _______________________ School. I am unable to produce a
(Name of School)
certified copy of the student’s birth certificate for the following reason:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________.
In lieu of a birth certificate I am providing other reliable proof of the
student’s identity and age in the form of:
 The student’s baptismal certificate
 A Family Bible that contains a written record of the student’s birth
 An alternate form of birth or hospital record
 The information listed below.
Name of Student: __________________________ Date of Birth: ___/____/____
Last
First
M.I.
Place of Birth: _____________/____________
City/State
Country
Month Day Year
Sex: ____________
Male or Female
Name of Mother appearing on Birth Record: _____________________________
Last
First
M.I.
Name of Father appearing on Birth Record: ______________________________
Last
First
M.I.
Signed: ________________________
Signature of Person Enrolling Student
___________________________
Notary Public
Notary, place stamp or seal above.