Indiana Certificate Of Live Birth Worksheet Template Page 5
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124 4 4 4 1 1 1 1 . FATHER: In what State, U.S. territory, or foreign country was he born?
. FATHER: In what State, U.S. territory, or foreign country was he born? Please specify one of
Please specify one of
. FATHER: In what State, U.S. territory, or foreign country was he born?
. FATHER: In what State, U.S. territory, or foreign country was he born?
Please specify one of
Please specify one of
t t t t he following:
he following:
he following:
he following:
State __________________________________ County ____________________________ City ___________________________
OR U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Northern Marianas
____________________________ OR Foreign country ___________________________________________
UNKNOWN
4 4 4 4 2 2 2 2 . What is the father’s Social Security Number? If you are not married, or if a paternity
. What is the father’s Social Security Number? If you are not married, or if a paternity
. What is the father’s Social Security Number? If you are not married, or if a paternity
. What is the father’s Social Security Number? If you are not married, or if a paternity
acknowledgment has not been completed, leave this item blank.
acknowledgment has not been completed, leave this item blank.
acknowledgment has not been completed, leave this item blank.
acknowledgment has not been completed, leave this item blank.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - - -
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
- - - _ _ _
_ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ - - -
- - - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
- - -
- - -
_ _ _
_ _ _
_ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _
- - -
- - -
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
4 4 4 4 3 3 3 3 . What is the highest level of schooling that the FATHER will have completed at the time of
. What is the highest level of schooling that the FATHER will have completed at the time of
. What is the highest level of schooling that the FATHER will have completed at the time of
. What is the highest level of schooling that the FATHER will have completed at the time of
delivery? (Check the box that best describes his education. If he is currently enrolled, check the
delivery? (Check the box that best describes his education. If he is currently enrolled, check the
delivery? (Check the box that best describes his education. If he is currently enrolled, check the
delivery? (Check the box that best describes his education. If he is currently enrolled, check the
box that indicates th
box that indicates th
box that indicates th
box that indicates the previous grade or highest degree received).
e previous grade or highest degree received).
e previous grade or highest degree received).
e previous grade or highest degree received).
8th grade or less
9th - 12th grade, no diploma
High school graduate or GED completed
Some college credit but no degree
Associate degree (e.g. AA, AS)
Bachelor’s degree (e.g. BA, AB, BS)
Master’s degree (e.g. MA, MS, MEng, MEd, MSW, MBA)
Doctorate (e.g. PhD, EdD) or Professional degree (e.g. MD, DDS, DVM, LLB, JD)
44. What is the father's usual occupation or industry. Please fill in below. For example his occupation is
Photographer, Farmer, Nurse, etc., and the industry in which he works is Factory, Skating Rink, Army,
etc.
Usual Occupation: _____________________________________________________________________
Usual Industry: ________________________________________________________________________
Unemployed
Unknown
4 4 4 4 5 5 5 5 . Is th
. Is the father Spanish/Hispanic/Latino? If not Spanish/Hispanic/Latino, check the “No” box. If
e father Spanish/Hispanic/Latino? If not Spanish/Hispanic/Latino, check the “No” box. If
. Is th
. Is th
e father Spanish/Hispanic/Latino? If not Spanish/Hispanic/Latino, check the “No” box. If
e father Spanish/Hispanic/Latino? If not Spanish/Hispanic/Latino, check the “No” box. If
Spanish/Hispanic/Latino, check all that apply.
Spanish/Hispanic/Latino, check all that apply.
Spanish/Hispanic/Latino, check all that apply.
Spanish/Hispanic/Latino, check all that apply.
No, not Spanish/Hispanic/Latino
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, other Spanish/Hispanic/Latino (e.g. Spaniard, Salvadoran, Dominican, Columbian)
(specify)____________________________________
4 4 4 4 6 6 6 6 . . . . What is th
What is the father’s race? Please check one or more races to indicate what he considers
e father’s race? Please check one or more races to indicate what he considers
What is th
What is th
e father’s race? Please check one or more races to indicate what he considers
e father’s race? Please check one or more races to indicate what he considers
himself to be.
himself to be.
himself to be.
himself to be.
White
Black or African American
American Indian or Alaska Native (name of enrolled or principal tribe)
_________________________________________
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian (specify)_____________________________________
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander (specify)_______________________________
Other (specify) ___________________________________________
5/25/2012
PAGE 5
VERSION 27 INDIANA'S BIRTH WORKSHEET
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