Form : Vr-22 Report Of Paternity Determination
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STATE OF COLORADO
REPORT OF PATERNITY DETERMINATION
This form can be filled out and printed at the following Web address: https:// This
document must contain the signature and seal of the District/Juvenile court and cannot be submitted online. You may fax form: 1-877-260-4080.
first
middle
last
1. CHILD’S NEW NAME:
PARENTS: THE INFORMATION IN THIS BOX WILL APPEAR ON THE CHILD’S NEW BIRTH CERTIFICATE
first
middle
maiden name
2. MOTHER’S MAIDEN NAME:
state
country if not U.S.A
2A. MOTHER’S BIRTH DATE
2B. MOTHER’S BIRTH PLACE:
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middle
last
3. FATHER’S FULL NAME:
state
country if not U.S.A
3A. FATHER’S BIRTH DATE
3B. FATHER’S BIRTH PLACE:
street or box #
4. MOTHER’S CURRENT MAILING ADDRESS:
city/town
state
zip
4A. MOTHER’S DAYTIME PHONE #:
—
—
street or box #
5. FATHER’S CURRENT MAILING ADDRESS:
city/town
state
zip
5A. FATHER’S DAYTIME PHONE #:
—
—
5B. Parents’ Driver’s License #: State of License Expiration Date
Attorney ID #:
ATTORNEY OR AGENCY
(To be contacted for additional information if needed)
6. CONTACT NAME:
6A. FIRM OR AGENCY:
street or box #
city/town
state
zip
6B. ADDRESS:
6C. CONTACT PHONE #:
—
—
6D. E-MAIL ADDRESS:
THIS INFORMATION IS NEEDED TO LOCATE AND SEAL THE ORIGINAL BIRTH CERTIFICATE
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middle
last
7. CHILD’S NAME AT BIRTH:
7A. SEX:
------------
county state country if not U.S.A
8B. BIRTHDATE:
8C. BIRTHPLACE:
first
middle
maiden name
8. MOTHER’S MAIDEN NAME:
first
middle
last
9. FATHER’S NAME:
CERTIFICATION OF CLERK OF COURT
I hereby certify that the child identified above was decreed to be the child of the above named parents on the ______ day of __________________,
20_____ and is now to bear the name of ______________________________________________________________________________________
as set forth in the decree of Paternity in the District/Juvenile Court of ________________________________County, Colorado.
Case number _______________ Signature and seal of court _______________________________________________ Date _____/_____/_______
By _____________________________________________________ Deputy Clerk
Return form to:
Contact information:
Vital Records/Paternity Determination
Colorado Department of Public Health and Environment
Vital Records Paternity Specialist
4300 Cherry Creek Drive South
Phone: 303-692-2230
Denver, CO 80246-1530
E-mail: vital.records@state.co.us
Fax: 1-877-260-4080
Form VR-22
REV. 08/14
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