Request For Certified Copy Of Acknowledgement Of Paternity printable pdf download

Request For Certified Copy Of Acknowledgement Of Paternity

ALABAMA

REQUEST FOR CERTIFIED COPY OF ACKNOWLEDGEMENT OF PATERNITY

The fee for a record search is $15.00, which includes the cost of one certified copy OR Certificate of

Failure to Find. For additional copies of the same record ordered at the same time, the fee is $6.00

each. Make check or money order payable to the “State Board of Health.” Fees are non-refundable.

You must complete and sign the Applicant Section or your request cannot be processed.

MAIL THIS FORM TO:

ALABAMA DEPARTMENT OF PUBLIC HEALTH

CENTER FOR HEALTH STATISTICS

PO BOX 5625

Montgomery, AL 36103-5625

MONTGOMERY, AL 36103-5625

Number of Copies__________

Amount Paid____________________

FULL NAME

OF CHILD_________________________________________________________________________

First

Middle

Last

DATE OF BIRTH________________________________________ SEX_______________________

COUNTY OF BIRTH____________________________ HOSPITAL___________________________

FULL MAIDEN

NAME OF MOTHER_________________________________________________________________

FULL NAME

OF FATHER_______________________________________________________________________

APPLICANT SECTION (THIS SECTION MUST BE COMPLETED)

Falsely applying for a record is subject to a penalty upon conviction of up to three months in the county

jail or a fine of up to $500. Code of Alabama 1975, § 13A-10-109.

By signing , you are certifying you have a legal right to the record requested.

Your Signature__________________________________________Date_______________________

Print Your Name_____________________________ Daytime Phone(____)_____________________

Address___________________________________________________________________________

City____________________________________State_________________Zip___________________

Relationship (To person whose record is being requested)___________________________________

Reason For Request (if not immediate family)_____________________________________________

ADPH-HS-21 Rev. 10/2009

Request For Certified Copy Of Acknowledgement Of Paternity