Form Adph-Hs-75 - Request To Add Father To Child'S Alabama Birth Certificate

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REQUEST TO ADD FATHER TO CHILD’S ALABAMA BIRTH CERTIFICATE
Please complete this form to add the father’s information to the birth certificate of the child listed below. Before we begin to process
your request, additional information and/or documents are needed. Please answer the following questions and provide the documents
as indicated when you return this form. After reviewing the information you provide, we will advise you if other documents will be
required or if a court action is needed. If you are not a parent of the child or if you do not have legal custody of the child, we may not be
able to process your request.
The fee to prepare the new birth certificate is $25 which includes one certified copy of the new birth certificate. Additional copies of the
same record ordered at the same time are $6.00 each. Make check or money order payable to “State Board of Health.” Note that fees
are not refundable if the action cannot be completed because you did not provide the appropriate legal documents. However, we will
return the fee if we determine you are not legally authorized to make the request.
INFORMATION ON PERSON MAKING REQUEST
By signing, you are certifying you have a legal right to the record requested.
(THIS SECTION MUST BE COMPLETED) Anyone 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 Ala. 1975, § 13A-10-109.
Your Signature: ______________________________________________________ Date: __________________________________
Print Your Name: ____________________________________________ Daytime Phone: (______)___________________________
Address: ___________________________________________________________________________________________________
City: ___________________________________________ State: ________________________ Zip Code: _____________________
Your Relationship to Child: _____________________________________________________________________________________
Number of Birth Certificate Copies Requested: _______________________ Fee Enclosed: $________________________________
INFORMATION TO LOCATE CHILD’S BIRTH CERTIFICATE
Full Name of Child as Shown on Birth Certificate: ___________________________________________________________________
Date of Child’s Birth: ______________________________________ County of Child’s Birth: _________________________________
Mother’s Full Maiden Name: ____________________________________________________________________________________
Mother’s Legal Name at Time of Birth: ____________________________________________________________________________
INFORMATION RELATING TO SITUATION AT TIME OF BIRTH
[Needed to determine appropriate legal requirements for making requested change(s) to birth record].
1. Do you want the father’s name added to the child’s birth certificate?
_______Yes
_______No
2. Do you want to change the child’s name on the birth certificate when you add the
father’s name?
_______Yes
_______No
3. Was the mother married to anyone at the time of the child’s birth, or within 300 days
before the child’s birth?
_______Yes
_______No
4. Have the father and mother married since the child was born?
If Yes, send a certified copy of the marriage certificate.
_______Yes
_______No
5. Has an individual ever claimed to be the father of this child in court?
If Yes, send a certified copy of the court order.
_______Yes
_______No
6. Has the child support court or any other type of court ever declared an individual to
be the father of this child? If Yes, send a certified copy of the court order.
_______Yes
_______No
7. Has a court established legal custody for this child?
If Yes, send a certified copy of the custody order.
_______Yes
_______No
8. What is the Father’s name, date of birth, and state of birth?
Father’s name:____________________________________________________________________________________
Father’s date of birth: __________________________________
Father’s state of birth: ________________________
MAIL THIS COMPLETED FORM WITH THE APPROPRIATE FEE FOR THE NUMBER OF COPIES REQUESTED TO:
Center for Health Statistics
P. O. Box 5625
Montgomery, AL 36103-5625
If you have questions, call a Paternity Specialist at 334. 206.2637. Visit our website at:
ADPH-HS-75 Rev. 08/2010

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