Chicago, IL
Translation of a “Birth Certificate”
(print or type)
(Form JJG-4)
1. NAME: ______________________________________________________________
(First)
(Middle)
(Last)
2. Birth: -Place: __________________________________________________________
(City/Town)
(State/Province)
(Country)
-Date: ___________________________________________________________
(Month)
(Day)
(Year)
3. Father’s Name: _________________________________________________________
(First)
(Middle)
(Last)
4. Mother’s Name: ________________________________________________________
(First)
(Middle)
(Last)
5. Certificate Issued:
Date: _____________________________________________________________
(Month)
(Day)
(Year)
Place: ____________________________________________________________
(City/Town)
(State/Province)
(Country)
Magistrate: _______________________________________________________
(Full name)
6. Certificate Found: Archive or Register: ______________________________________
Page ___________________ No. ___________________________
7. Notations of Importance:
_______________________________________________________________________
________________________Certificate of Translation__________________________
I, (*) __________________, hereby certify that the above is an accurate translation of the
original “birth certificate” in (**) _____________; and that I am competent in both
English and (**) _____________ to render such translation.
_________________________________
(Signature of Translator)
__________________
(Date)
(*) Printed or typed, name of the translator in full
(**) Language of the original certificate- Spanish, French, Chinese, German, etc…
****Note: A copy of the original document should be attached to this summary
translation form and certification.