Office of the P.O.

Box 4600 Statement of Live Birth

Registrar 189 Red River Road
General Thunder Bay ON P7B 6L8 Form 2 Vital Statistics Act 1990
This is a permanent legal record. Office use only
Type or print plainly in blue or black ink and complete all items.
Please read all instructions before completing this form.

SECTION A - CHILD’S INFORMATION (see instruction #2)

Surname (Last Name) Sex of Child
CHANDRA Male
First Name Middle Name(s)
AARUSH
Birth Date Year Month Day Name of hospital (if not hospital give exact location where birth occurred)
2008 04 30 ST MICHAELS HOSPITAL
Place of Birth (City, town, village, township - by name) (Regional municipality, county or district)
TORONTO Toronto
SECTION B - MOTHER’S INFORMATION SECTION C - FATHER’S/OTHER PARENT’S INFORMATION
(see instruction #3) (see instruction #4)
Current Legal Surname (Last Name) Current Legal Surname (Last Name)
SAXENA CHANDRA
Legal Surname at Birth (Maiden Name)(see instruction #3b) First and Middle Names
SAXENA DEVESH
First and Middle Names Legal Surname at Birth (see instruction #4d)
RICHA CHANDRA
Any Other Legal Surnames Any Other Legal Surnames

Birthplace (City/town/village) Birthplace (City/town/village)

MORADABAD BAREILLY
Birthplace (Province/country) Birth Date Year Month Day Age Birthplace (Province/country) Birth Date Year Month Day Age
INDIA 1981 05 29 26 INDIA 1978 07 06 29
Mother’s Occupation Marital Status
HOUSEWIFE of Mother Single Married Common Law Divorced Widowed

SECTION D - BIRTH INFORMATION

Mother’s Residence - Complete street address (City, town, village, township - If rural give Post Office or Rural Route address) Postal Code
APT 1101, 33 WOOD ST, TORONTO, ONTARIO M4Y2P8
Mother’s Mailing Address if different from above - Complete street address (If rural give Post Office or Rural Route address ) Postal Code

Duration of Total number of children ever born Weight of child at birth Kind of Birth If multiple birth, state
pregnancy to this mother including this birth 1 whether this child was born
(in weeks) 3230
Grams__________ 1st, 2nd, 3rd, etc.
Of this Total, Number born live 1 Single Twin
40 Of this Total, Number stillborn or _____lb.___oz. Triplet Other
0
Name of Attendant at birth
DONNA STEELE Physician Midwife Other, specify:

SECTION E - BEFORE SIGNING PLEASE READ INSTRUCTIONS Certification of Informant (see instruction #2)
Before completing this section (see instruction 2c). If you are choosing a surname that is not one of the parent’s surnames or combination of
those names, but is in accordance with the child’s cultural, ethnic, or religious heritage, check one of the following boxes.
Cultural Heritage Religious Heritage Ethnic Heritage
I (We) certify the statements made on this form are true Signature of Mother Year Month Day
and correct. I am (We are) aware that it is an offence x
to wilfully make a false statement on this form.
Signature of Father/Other Parent Year Month Day
I (We) have agreed that the child’s surname will be as
shown in section A.
x
Signature of Informant (see instruction 2f) Year Month Day
Yes No x
SECTION F - DO NOT WRITE BELOW THIS LINE - OFFICE USE ONLY - Certification of Division Registrar
I am satisfied as to the correctness and sufficiency of these statements on this form and register the birth by signing this Registration Number
statement.
Signature of Division Registrar x
Division Registrar Code Number Year Month Day

For office use only

11022 (03/2007) © Queen’s Printer for Ontario, 2007 Français au verso

 Office of the
Registrar General

Statement of Live Birth - IMPORTANT Instructions

General Instructions: INSTRUCTION #1

a) This document is a permanent legal record. The child’s information will be registered as it appears on this form. Failure to
complete this document accurately will result in delays in registration.
b) It is an offence to intentionally lie on this statement. An individual who wilfully makes a false statement on the form, may on
conviction be liable to a maximum fine of $50,000 or imprisonment for a maximum term of 2 years less a day.
c) If you make a mistake when filling out this form, bracket and initial the error and enter the correct information. Use of correction
fluid will not be accepted. Any changes on the form must be initialed by each parent that signs the form.
d) The birth of every child born in the Province of Ontario must be registered within 30 days of the date of birth with the municipal
clerk of the municipality in which the child was born. The municipality may charge a fee for handling this form. This fee is not for a
birth certificate. An additional fee will be charged to obtain a birth certificate.

Child’s Name: INSTRUCTION # 2

a) First and middle names and surnames are not to be underlined or enclosed in brackets or quotation marks. Brackets are only used
to correct an error as required in the general instructions (above). Anything in brackets will be ignored.
b) The order in which the first and middle names are entered on this form is the order in which they will appear on an official birth
certificate, following the surname.
c) If both parents’ information is included on this form, the child’s surname may be either parent’s surname or former surname, or both
parents’ surnames or both parents’ former surnames hyphenated or combined. If only the mother’s information is included on the
form, the child’s surname may be the mother’s surname or former surname. The parent or parents who sign the form may also give
the child a surname based on the child’s ethnic, religious or cultural heritage. If this option is chosen, the parent(s) must check the
appropriate box in section E.
d) If the parents disagree on the child’s surname, the registered surname will be the parents’ surname if they have the same surname.
If the parents have different surnames, the child’s surname will be registered using both parents’ surnames hyphenated in
alphabetical order.
e) Each parent listed on the form must sign the form unless that parent is incapable of completing the birth registration form because
of illness or death. If one or both parents do not sign this form because they are incapable, a statutory declaration must be
submitted with this form. This statutory declaration is available from the municipal clerk of the municipality in which the child was
born or from the Office of the Registrar General.
f) Where neither parent signs this form because both parents are incapable, an informant acting on the mother’s behalf must
complete and sign the form. In this situation, the child’s surname must be 1) the parents’ surname, if they have the same surname;
2) a surname consisting of both parents’ surnames hyphenated in alphabetical order, if they have different surnames; or 3) if only
one parent is known, that parent’s surname.

Mother’s Information: INSTRUCTION # 3

a) The mother on the form must be the woman who gave birth to the child.
b) The mother’s legal surname at birth (maiden name) is the mother’s legal last name at the time of her own birth, unless the mother
was adopted. If the mother was adopted, enter her adoptive name if that is different than her surname at birth.
c) Different rules about who can be named on a birth registration apply if a person has been declared to be the parent of the child by a
court order issued under the Children’s Law Reform Act or an adoption order.

Father’s/Other Parent’s Information: INSTRUCTION # 4

a) A “Father”, for the purposes of this form, must be the biological father of the child and consent to be acknowledged as the father.
b) An “Other Parent”, for the purposes of this form, must be another person who consents to be acknowledged as the parent, if the
biological father is unknown and the child was born of assisted conception with an anonymous sperm donor.
c) The father’s/other parent’s information may be included on the form, if the mother acknowledges that person as a parent of the
child.
d) The father’s/other parent’s legal surname at birth is the person’s legal last name at the time of his/her birth, unless adopted. If
adopted, enter the father’s/other parent’s adoptive name if that is different than the surname at birth.
e) If a father’s/other parent’s information is on the form, that parent must also sign this sign this form unless they are incapable of
completing the birth registration form because of illness or death.
f) Different rules about who can be named on a birth registration apply if a person has been declared to be the parent of the child by a
court order issued under the Children’s Law Reform Act or an adoption order.

Personal information contained on this form is collected under the authority of the Vital Statistics Act, R.S.O. 1990, c.V.4 and will be used to
register and record births, stillbirths, deaths, marriages, additions or changes of name, corrections or amendments, provide certified
copies, extracts, certificates, search notices, photocopies, and for statistical, research, medical, law enforcement, adoption and adoption
disclosure purposes. It is an offence to wilfully make a false statement on this form. Questions about this collection should be directed to:
The Deputy Registrar General, Office of the Registrar General, P.O. Box 4600, Thunder Bay ON P7B 6L8. Telephone 1-800-461-2156 or
416-325-8305.

11022 (03/2007) ©Queen’s Printer for Ontario, 2007 Français au verso

Birth Registration (Statement of Live Birth) Information and Instructions

Mailing Information

Send the birth registration to:

City of Toronto
399 The West Mall, Main Floor
Etobicoke, ON
M9C 2Y2

Payment Information

Total Registration Fee $35.00

Payment Type Credit Card – VISA
Card Number 4505530024451864
Expiry Date Month 07 Year 2010
Name of Cardholder DEVESH CHANDRA
Signature

You must sign the credit card section in order for the payment to be valid.

Birth Registration Form Instructions

Step 1 You must send the birth registration form to the address above.

Step 2a If you are paying using a credit card you must sign the credit card section of this page and send it
to the municipality along with the birth registration form.
Step 2b If you are paying using cheque or money order you must send your payment to the municipality
along with the birth registration form.

The birth of every child born in the Province of Ontario must be registered within 30 days of the
date of birth with the municipal clerk of the municipality in which the child was born.
Any parent whose information is included on the form, unless that parent is incapable due to
illness or death, must sign the birth registration form.
Do not use correction fluid (white-out) on the birth registration form. If an error is made, bracket
the error and initial any changes.