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FLORIDA PUTATIVE FATHER REGISTRY

CLAIM OF PATERNITY

Clear Form

CAREFULLY READ the information provided on the reverse of this form. PLEASE TYPE OR PRINT CLEARLY.

Part 1 PUTATIVE FATHER'S (REGISTRANT) INFORMATION TO BE INCLUDED IN PUTATIVE FATHER REGISTRY

FIRST

MIDDLE

LAST INCLUDING ANY SUFFIX

DATE OF BIRTH

FULL NAME OF

FATHER

CITY

STATE

ZIP CODE

RESIDENCE STREET ADDRESS (AND APT.)

CITY

STATE

ZIP CODE

ALTERNATE ADDRESS (AND APT.), IF APPLICABLE

PLEASE PROVIDE A PHYSICAL DESCRIPTION OF FATHER

Part 2 CONCEPTION INFORMATION

DATE OF CONCEPTION (MONTH, DAY, YEAR)

PLACE AND LOCATION OF CONCEPTION (Not limited to, but including city and state)

Part 3 AGENT/REPRESENTATIVE APPOINTMENT To receive notice of pending adoption, you MUST provide address information. This address cannot be a post office

box. If you choose, you may designate another person as an agent or representative to receive notice of any termination of parental rights proceeding and /or adoption

that is filed regarding the mother and child listed on this form. Said agent or representative MUST sign the acceptance of designation below in order to receive notice or

service of process.

FIRST

MIDDLE

LAST

SUFFIX

PRINTED FULL NAME OF

AGENT OR

REPRESENTATIVE

CITY

STATE

ZIP CODE

RESIDENCE STREET ADDRESS (AND APT.)

SIGNATURE OF AGENT OR REPRESENTATIVE

Part 4 MOTHER'S INFORMATION (If date of birth unknown, provide approximate age of

mother)

FIRST

MIDDLE

MAIDEN, IF KNOWN or LEGAL SURNAME

DATE OF BIRTH

FULL NAME OF

MOTHER

CITY

STATE

ZIP CODE

RESIDENCE STREET ADDRESS (AND APT.)

PLEASE PROVIDE A PHYSICAL DESCRIPTION OF MOTHER

Part 5 CHILD'S INFORMATION (If exact date of birth unknown, provide estimated date of birth OR anticipated date of delivery in case where birth has

not yet occurred).

FIRST

MIDDLE

LAST INCLUDING SUFFIX

SEX

FULL NAME OF

CHILD

CITY OF BIRTH

COUNTY OF BIRTH

STATE OF BIRTH

DATE OF BIRTH (MM/DD/YYYY)

FEE FOR FILING AND INDEXING YOUR CLAIM OF PATERNITY IN THE FLORIDA PUTATIVE FATHER REGISTRY

$9.00

Check or money order payable to Vital Statistics

in U.S. Dollars (

DO NOT SEND CASH)

PUTATIVE FATHER'S ACKNOWLEDGMENT

To provide false information for fraudulent purposes is a third-degree felony punishable by the terms and conditions as set forth in Florida Statutes

It is my belief that I am the UNMARRIED BIOLOGICAL FATHER of the above child and that I wish

Personally Known

Produced Identification

to assert my rights as the father. I understand that my name and information will be included in

the

Putative Father Registry maintained by the State Office of Vital Statistics, Florida

Department of Health and that by filing this Claim of Paternity it serves as confirmation of my

willingness and intent to support the child for whom paternity is claimed in accordance with

state law.

Type of Identification Produced

_______________________________________________________________________________________

PRINTED NAME OF PUTATIVE FATHER

_______________________________________________________________________________________

SIGNATURE OF PUTATIVE FATHER

(Place Notary Stamp Here)

State of ___________________________ County of ________________________________

Subscribed and sworn before me this __________ day of ________________, 20 ________

__________________________________________________________________________________

PRINTED NAME OF NOTARIZING OFFICIAL

____________________________________________________________________________________

SIGNATURE OF NOTARIIZING OFFICIAL

____

DH1965

(10/03)

Claim Of Paternity

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