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Department of Health
Office of Vital Statistics
Certified Statement of Final Judgment of Paternity
Paternity Establishment/Paternity Disestablishment
(Please refer to instructions on reverse side)
Check appropriate action: Paternity Establishment
Paternity Disestablishment
Department of Revenue/Child Support Enforcement Action
: Yes
No
A. INFORMATION FROM ORIGINAL BIRTH RECORD
(Attach a Photocopy or Screen Print)
State of Birth: _________________________________________ Birth Number (if known): __________________________
Full Name of Child: ______________________________________________________________________ Sex: _________
(First)
(Middle)
(Last)
Date of Birth: ___________________________ Place of Birth: ________________________________________________
(Month, Day, Year)
(City)
(County)
Name of Father: _____________________________________________________________________
______
If no father's name on original, enter 'NO FATHER NAMED'
Maiden Name of Mother: ___________________________________________________________________
(First)
(Middle)
(Last)
Maiden
B. INFORMATION FOR NEW CERTIFICATE
NOTE: If child's name is to be changed as part of this paternity action, it MUST be included in the court order and
entered below as shown in the court order. See additional information in Paragraph 2 on the reverse side of this form.
Full Name of Child: ______________________________________________________________________________________
(First)
(Middle)
(Last)
Full Name of Father: ________________________________________________________________
______________
(First)
(Middle)
(Last)
Date of Birth of Father: ___________________________________________ Place of Birth of Father: ____________________
(Month, Day, Year)
(State)
Name and mailing address of custodial parent: _________________________________________________________________
(Middle)
(Last)
(First)
_________________________________________________________________
(Street or P. O. Box)
(City)
(State)
( Zi
p Code)
Father's Social Security No.: ____________________________
Mother's Social Security No.: _________________________
Attorney's Name
OR person completing form:
Phone Number:
(if applicable)
Address: _______________________________________________________________________________________________
(Street or P. O. Box)
(City)
ode)
(State)
(Zip C
X
______________________________________________________________________________________________
(If Attorney - Provide Bar Number)
(Signature of Attorney OR person comp
leting form)
C. CERTIFICATE OF CLERK OF CIRCUIT COURT
On the _______ day of ___________________________, A.D. 20____, the Circuit Court of _____________________________
red a Judgment of Paternity in the case of the child and
County, Judge ________________________________presiding, orde
parents described above.
Signed and Sealed by __________________________
Date: ___________
Court Docket No.
(Clerk of the Circuit Court)
DH Form 673, 8/06 (Replaces previous
edition which may not be used)