Texas Notice Of Intent To Claim Paternity
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1
2NOTICE OF INTENT TO CLAIM PATERNITY
INSTRUCTIONS/INFORMATION
1.
Carefully read the information provided on the reverse of this form. The information provided is not designed to be legal
advice. Questions concerning paternity, presumptions of paternity, or rights and responsibilities of a parent should be
directed to an attorney.
2.
Please type or print neatly.
3.
All information in Part 1 concerning the father is required. Do not leave any of these items blank.
4.
Complete Part 2 and Part 3 to the best of your ability. If any item is unknown, leave the space blank.
5. The child’s name, date of birth, place of birth, and mother’s maiden name are very critical to linking the Notice of Intent to
Claim Paternity with an actual child. The more complete the information you provide, the more effective the paternity registry
can be.
Part 1 MAN’S INFORMATION TO BE INCLUDED IN PATERNITY REGISTRY:
1. FULL NAME
FIRST
MIDDLE
LAST
2. DATE OF BIRTH (MM/DD/YYYY)
3. SOCIAL SECURITY NUMBER
4. DRIVER’S LICENSE NUMBER
STATE
NUMBER
5. RESIDENCE ADDRESS
NUMBER & STREET NAME
CITY
STATE
ZIP
6. MAILING ADDRESS
NUMBER & STREET NAME
CITY
STATE
ZIP
Part 2 CHILD’S INFORMATION:
7. FULL NAME
FIRST
MIDDLE
LAST
8a. DATE OF BIRTH (MM/DD/YYYY)
8b. EXPECTED DATE OF BIRTH (MM/DD/YYYY)
9. SEX
10a. BIRTHPLACE (HOSPITAL NAME)
10b. CITY OF BIRTH
10c. COUNTY OF BIRTH
10d. STATE OF BIRTH
Part 3 MOTHER’S INFORMATION:
11. FULL NAME
FIRST
MIDDLE
LAST
MAIDEN
12. DATE OF BIRTH (MM/DD/YYYY)
13. SOCIAL SECURITY NUMBER
14. DRIVER’S LICENSE NUMBER
STATE
NUMBER
15. LAST KNOWN ADDRESS
NUMBER & STREET NAME
CITY
STATE
ZIP
I declare under penalty of perjury that I am the father of the above child. I understand my name and information will be included in the
paternity registry maintained by the Vital Statistics, Texas Department of State Health Services. I further understand that:
•
Placing this form on file with Vital Statistics, Texas Department of State Health Services, entitles me to notice of
proceeding for adoption of the child named above or for termination of my parental rights;
•
Placing this form on file does not establish legal paternity of the child and does not begin the process of
establishing legal paternity of the child;
•
The information contained in this form may be used in a legal proceeding to establish paternity of the child.
__________________________________________
SIGNATURE OF MAN
VITAL STATISTICS USE ONLY
ACTUAL NAME OF CHILD _____________________________________________________
NOTICE SENT TO MOTHER
DOB _________________________ STATE FILE # _________________________________
DENIAL RECEIVED
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