Free 46750.pdf - Indiana

INDIANA PUTATIVE FATHER REGISTRATION
State Form 46750 (R2/11-04)

This form is confidential and release may be made only under I.C. 31-3-1.5

Instructions: Return this completed form to the Indiana Putative Father Registry within 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: ________________________________________________________________________________________ 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. 31-3-1.5-11. 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: ________________________________________________________________________________________ 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: ________________________________________________________________________________________ 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: _____________________________
Month Day Year

Place of Birth: _______________________________________

*******************************************************************************************************************

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______________________________________________________________________________
Signature of Putative Father Date

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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