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________________________________________________ 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.