Form 04-1423a - Paternity Information Locate Sheet Page 2
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22) Full Name:__________________________________________________________________
First
Middle
Last
Address:____________________________________________________________________
City
State
Zip
Date and Place of Birth:___________________________________ Approximate Age:______
Physical description: __________________________________________________________
Height
Weight
Hair Color
Eye Color
Race
Social Security Number:________________________________________________________
Dates of sexual relations: From ________________________ To______________________
Why do you think that this man is not the father? ____________________________________
___________________________________________________________________________
If you do not know the father of your child, explain the circumstances when you became
pregnant______________________________________________________________________
_____________________________________________________________________________
Information about the child:
Name:
Male
Female
Conception date___________________ Social Security Number_______________________
Date of Birth: _______________________Place of Birth: ____________________________
Have there been any legal actions for this child (such as child support orders, adoption, children's
proceedings, paternity cases, divorce decree, etc.)? If so, what action, where, and when? Attach
copies of legal documents.________________________________________________________
Is a father named on the child's birth certificate?
Yes
No
Did the father sign an affidavit of paternity?
No
Yes Place:________________________
City
State
Were you married when the child was conceived or born?
No.
Yes.
Husband’s name___________________________ Social Security Number__________________
Your Work telephone number_________________ Home telephone number: ________________
Address:_______________________________________________________________________
City
State
Zip
Social Security Number________________________ Date of Birth: _______________________
Your Employer__________________________________________________________________
Address
City
State
Zip Code
__________________________________
________________________________ ________________________
Your name (PLEASE PRINT)
Signature
Date
THANK YOU FOR PROVIDING THIS INFORMATION
04-1423A (Rev 08/15/11)
MAT-SU: (907) 357-3550
TOLL FREE (In-state, outside Anchorage): (800) 478-3300
SOUTHEAST: (907) 465-5887
ANCHORAGE: (907) 269-6900
FAX: (907) 787-3220
FAIRBANKS: (907) 451-2830
TDD machine only: (907) 269-6894 / TDD machine only, toll free (In-state, outside Anchorage): (800) 370-6894
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