Ocfs - New York State Request / Response For Name And / Or Adress Of Father Of Child Born Out Of Wedlock

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LDSS-2725 (Rev. 9/2009)
FORWARD ORIGINAL
NEW YORK STATE
OFFICE OF CHILDREN AND FAMILY SERVICES
TO:
REQUEST/RESPONSE FOR NAME AND/OR ADDRESS
NYS OCFS
Putative Father Registry
OF FATHER OF CHILD BORN OUT OF WEDLOCK
(Print or Type All Information)
REQUEST DATE:
REQUEST
(Please: One form per child)
FATHERS SOCIAL SECURITY #
FATHER’S NAME:
REQUESTING AGENCY (Name and Address):
(If Known):
CHILD’S DATE OF BIRTH
CHILD’S NAME:
REQUIRED
MOTHER’S SOCIAL SECURITY #
MOTHER’S NAME:
(If Known):
SIGNATURE OF AGENCY OFFICIAL:
PRINT NAME OF AGENCY OFFICIAL:
AGENCY TEL. NO.(include Area Code):
REQUIRED
The department shall, upon request, provide the names and addresses of persons listed with the
registry to any court or authorized NYS agency, and such information shall not be divulged to any
other person, except upon order of a court for good cause shown. Social Service Law 372-c Putative
Father Registry
INSTRUCTIONS:
1. COMPLETE ALL THE BOXES ABOVE. If you complete on-line, print and then sign the document. If you complete
hard copy please print neatly and sign in the Agency Official Box.
2. IF THE MOTHER DOES NOT NAME THE FATHER IN ANY AFFIDAVIT, OR IF THE FATHER’S NAME DOES NOT
APPEAR ON THE CHILD’S BIRTH CERTIFICATE, LIST THE FATHER’S NAME AS “UNKNOWN”.
3. MAIL ONLY ONE (1) COPY TO:
NYS-OCFS
NYSAS/Putative Father Registry
52 Washington Street, Room 323 North
Rensselaer, New York, 12144
RESPONSE DATE:
STAFF REGISTRAR – PUTATIVE FATHER REGISTRY:
RESPONSE
REGISTRY INFORMATION
DOCUMENT TYPE:
Acknowledgement of Paternity
Court Order
Instrument to Acknowledge Paternity
Other
PUTATIVE FATHER’S NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
DATE REGISTERED:
ADDRESS:
DATE OF COURT ORDER:
DOCKET NUMBER:
COURT:

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