Non-Owner Membership Registration Form Page 2

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______________________________________________________________________________
Signature of Putative Father
Date (month, day, year)
__________________________________
STATE OF INDIANA, COUNTY OF
SS:
Before me, a Notary Public in and for said County and State, personally appeared
___________________________________________________________________________________,
who, having been first duly sworn upon his/her oath, stated the foregoing representations are
_________________________________,
true this ____________________ day of
20 __________.
______________________________________
Signature
______________________________________
Printed Name
______________________________________
My Commission Expires:
______________________________________
My County of Residence:
Send this completed form to:
Indiana Putative Father Registry
Indiana State Department of Health
Vital Records Division, B-4
2 North Meridian Street
Indianapolis, Indiana 46204
Fax Number: 317.233.1289
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