Non-Owner Membership Registration Form
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INDIANA PUTATIVE FATHER REGISTRATION
This form is confidential and release may
State Form 46750 (R3 / 1-11)
be made only under I.C. 31-19-5-9.
Instructions:
Return this completed form to the Indiana Putative Father Registry within thirty (30) days after the birth
of the child or prior to the filing of the petition for adoption.
This form must be signed and notarized to be valid for filing.
Information about you
Name: __________________________________________________________________________________________
: ________________________________________________________________________
Address
(number and street)
City, State, and ZIP Code: _________________________________________________________________________
Social Security Number*: _____________________________
Date of Birth: __________________________
Month
Day
Year
* This State Agency is requesting your Social Security Number in accordance with I.C. 31-19-5-9.
Disclosure is mandatory, and this record cannot be processed without it.
**************************************************************************************************
Information about your designated agent (optional)
If you do not have an address where you can receive notice of an adoption, you may designate another person as your agent.
I designate the following person as my agent to receive notice of an adoption that is filed regarding the mother and child
that I list on this form:
Name: __________________________________________________________________________________________
: ________________________________________________________________________
Address
(number and street)
City, State, and ZIP Code: _________________________________________________________________________
**************************************************************************************************
Information about the child's mother (please provide the following information, if known)
: ________________________________________
Name
(include all names that you believe she may use or has used)
_________________________________________________________________________________________________
: ________________________________________________________________________
Address
(number and street)
City, State, and ZIP Code: _________________________________________________________________________
Social Security Number: _____________________________
Date of Birth: __________________________
Month
Day
Year
**************************************************************************************************
Information about the child (please provide the following information, if known)
Name: ___________________________________________________________________________________________
Date of Birth: _____________________________
Place of Birth: _______________________________________
Month
Day
Year
**************************************************************************************************
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