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IDENTIFYING INFORMATION ABOUT THE CHILD:

Child’s

LAST Name __________________________________

FIRST Name ______________________________MIDDLE Name_______________

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SEX

Male

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Race______________________________________

CHECK ONE

Female

Date of Birth (MM/DD/YY) ____________________________

Estimated Due Date of Mother (MM/YY) ______________________

Child’s Birthplace

City_____________________________________________________

State ____________________________________________________

Hospital name, if any:

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Birth Certified

Father Certified By State

Multiple Birth

INFORMATION ABOUT INTERESTED PARTY REQUESTING SEARCH OF PUTATIVE FATHER REGISTRY:

If Firm or Agency, Name______________________________________________________________________________________________

Name of Person(s) Requesting Search ________________________________________________________________________________

Phone Number (000/000/0000) ___________________________________

Fax Number (000/000/0000)________________________

Person Requesting Search is:

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Mother of Child

Child Welfare Agency

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Attorney representing Mother of Child

Attorney representing Child Welfare Agency

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Attorney arranging a Minor’s Adoption

Address for Notice of Search Results

Street Number____________________________________________ Street Name _____________________________________________

City______________________________________________________ State __________________________ Zip ______________________

I certify that the information provided in the Search Request Form is true and correct to the best of my knowledge. I further certify that I am

requesting this search of the Putative Father Registry to determine whether a putative father is registered in relation to the child referenced above,

who is or may be the subject of an adoption petition, and the information obtained will be used for this purpose only.

Signature of individual requesting search

I have read, or someone has read to me, the instructions to Putative Fathers before signing this form, and I understand that completing

this form is not enough to protect my rights to be legal father of the child identified on this form. For further information on filing a

parentage action form contact:

Office of Child Support Enforcement

Ohio Department of Job and Family Services

50 W. Broad Street, 4

Floor

Columbus, Ohio 43215

1-800-686-1556 (in Ohio), or (614) 752-9743

I certify that the information provided above is true and correct to the best of my knowledge. I understand that a person who knowingly

or intentionally registers false information on this form commits a Misdemeanor of the First Degree.

I understand that I must tell the Putative Father Registry, if I change my address or if any other information changes on the form, so

that I can be located if the child I have identified becomes the subject of an adoption.

________________________________

______________________________________________________________

Date

Signature of Putative Father

STATE OF ______________________________________________, County of ____________________________________________,

Before me, a Notary Republic in and for said County and State, personally appeared _________________________________________________

who, have been duly sworn upon his/her oath, stated the foregoing representatives are true this ______________ day of _________________

JFS 01694 (REV. 9/2003)

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Application For Search Of Ohio Putative Father Registry - Ohio Department Of Job And Family Services Page 2

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