Fillable FLORIDA PUTATIVE FATHER REGISTRY CLAIM OF PATERNITY (Duval County Clerk of Courts)

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FLORIDA PUTATIVE FATHER REGISTRY CLAIM OF PATERNITY (Duval County Clerk of Courts)

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FLORIDA PUTATIVE FATHER REGISTRY
CLAIM OF PATERNITY
CAREFULLY READ the information provided on the reverse of this form. PLEASE TYPE OR PRINT CLEARLY.
Part 1 PUTATIVE FATHER'S (REGISTRANT) INFORMATION TO BE INCLUDED IN PUTATIVE FATHER REGISTRY
FULL NAME OF
FATHER
FIRST MIDDLE LAST INCLUDING ANY SUFFIX DATE OF BIRTH
RESIDENCE STREET ADDRESS (AND APT.)
CITY STATE ZIP CODE
ALTERNATE ADDRESS (AND APT.), IF APPLICABLE
CITY STATE ZIP CODE
PLEASE PROVIDE A PHYSICAL DESCRIPTION OF FATHER
Part 2 CONCEPTION INFORMATION
DATE OF CONCEPTION (MONTH, DAY, YEAR)
PLACE AND LOCATION OF CONCEPTION (Not limited to, but including city and state)
Part 3 AGENT/REPRESENTATIVE APPOINTMENT To receive notice of pending adoption, you MUST provide address information. This address cannot be a post office
box. If you choose, you may designate another person as an agent or representative to receive notice of any termination of parental rights proceeding and /or adoption
that is filed regarding the mother and child listed on this form. Said agent or representative MUST sign the acceptance of designation below in order to receive notice or
service of process.
PRINTED FULL NAME OF
AGENT OR
REPRESENTATIVE
FIRST MIDDLE LAST SUFFIX
RESIDENCE STREET ADDRESS (AND APT.)
CITY STATE ZIP CODE
SIGNATURE OF AGENT OR REPRESENTATIVE
Part 4 MOTHER'S INFORMATION (If date of birth unknown, provide approximate age of
mother)
FULL NAME OF
MOTHER
FIRST MIDDLE MAIDEN, IF KNOWN or LEGAL
SURNAME
DATE OF BIRTH
RESIDENCE STREET ADDRESS (AND APT.)
CITY STATE ZIP CODE
PLEASE PROVIDE A PHYSICAL DESCRIPTION OF MOTHER
Part 5 CHILD'S INFORMATION (If exact date of birth unknown, provide estimated date of birth OR anticipated date of delivery in case where birth has
not yet occurred).
FULL NAME OF
CHILD
FIRST MIDDLE LAST INCLUDING SUFFIX SEX
DATE OF BIRTH (MM/DD/YYYY)
CITY OF BIRTH COUNTY OF BIRTH STATE OF BIRTH
FEE FOR FILING AND INDEXING YOUR CLAIM OF PATERNITY IN THE FLORIDA PUTATIVE FATHER REGISTRY
Check or money order payable to
Vital Statistics
in U.S. Dollars (DO NOT SEND CASH)
$9.00
PUTATIVE FATHER'S ACKNOWLEDGMENT
To provide false information for fraudulent purposes is a third-degree felony punishable by the terms and conditions as set forth in Florida Statutes
It is my belief that I am the UNMARRIED BIOLOGICAL FATHER of the above child and that I wish
to assert my rights as the father. I understand that my name and information will be included in
the Putative Father Registry maintained by the State Office of Vital Statistics, Florida
Department of Health and that by filing this Claim of Paternity it serves as confirmation of my
willingness and intent to support the child for whom paternity is claimed in accordance with
state law.
_______________________________________________________________________________________
PRINTED NAME OF PUTATIVE FATHER
_______________________________________________________________________________________
SIGNATURE OF PUTATIVE FATHER
Personally Known or Produced Identification
Type of Identification Produced
State of ___________________________ County of ________________________________
Subscribed and sworn before me this __________ day of ________________, 20 ________
__________________________________________________________________________________
PRINTED NAME OF NOTARIZING OFFICIAL
____________________________________________________________________________________
____
SIGNATURE OF NOTARIIZING OFFICIAL
(Place Notary Stamp Here)
DH1965
(10/03)
Print Form
Clear Form
IMPORTANT INFORMATION CONCERNING
FLORIDA PUTATIVE FATHER REGISTRY - CLAIM OF PATERNITY
Statute references may be accessed through the website address at the bottom of this form*
BACKGROUND AND PURPOSE Section 63.054, Florida Statutes has provided for the establishment of a Putative Father Registry in the Office of
Vital Statistics (OVS), Florida Department of Health (DOH). The purpose of the registry is to permit a man alleging to be the biological father of a
child to assert his parentage, independent of the mother, and preserve his rights as a parent. This registry also may expedite adoptions of children
whose biological fathers are unwilling to assume responsibility of their child. For purposes of this provision registrant means an "unmarried
biological father". The information provided is not designed to be legal advice. Questions concerning paternity, presumptions of paternity, or rights
and responsibilities of a parent should be directed to an attorney.
If an unmarried biological father fails to take the actions that are available to him to establish a relationship with his child, his parental interest may
be lost entirely, or greatly diminished, by his failure to timely comply with the available legal steps to substantiate a parental interest.
A man is presumed to be the biological father and is not required to register with the paternity registry if:
1) he was married to the mother at the time of the child's birth;
2) the mother was not married at the time of the birth and the man acknowledged paternity at the hospital at the time of the child's birth;
3)
the mother was not married at the time of birth and the man acknowledged paternity subsequent to the birth by filing a Consenting
Affidavit Acknowledging Paternity, DH 432 with OVS and the record has been amended to reflect him as father; OR
4) paternity has been established by court order.
INFORMATION FOR COMPLETING CLAIM OF PATERNITY FORM - Type or print neatly. This form MUST be signed under oath.
•
All information in Part 1 concerning the father is required. Do not leave any of these items blank.
• Complete Parts 2, 4 & 5 to the best of your ability. If an item is unknown, leave the space blank. The child's name, date of birth, place of
birth, and the mother's maiden name are critical to linking the Claim of Paternity with an actual child. The more complete the information
you provide, the more effective the paternity registry can be. If mother's maiden name is unknown but her legal surname is known, please
provide legal surname and indicate that name provided is legal surname. If you have named an agent/representative to act on your behalf,
said agent or representative MUST file an acceptance of the designation, in writing, in order to receive notice or service of process.
•
A Claim of Paternity may be filed any time prior to the birth BUT a claim of paternity may not be filed after the date a petition is filed for
termination of parental rights.
•
By filing this claim of paternity, the registrant expressly consents to submit to DNA testing upon the request of any party, the registrant, or
the adoption entity with respect to the child referenced in the claim of paternity.
•
The registrant may, at any time prior to the birth of the child for whom paternity is claimed, execute a notarized written revocation of the
claim of paternity previously filed and upon such revocation, the claim of paternity shall be deemed null and void. A Claim of Paternity -
Update to Registration form is available for this purpose.
•
If the court determines that a registrant is not the father of the minor, the court shall order the department to remove the registrant's name
from the registry.
•
It is the obligation of the registrant or, if designated an agent or representative, to notify and update the information contained in the
registry in OVS of any change of address or change in the designation of an agent or representative. A Claim of Paternity - Update to
Registration form is available for this purpose.
•
OVS will notify the registrant, in writing, of their receipt of a Claim of Paternity OR a Revocation filed on a Claim of Paternity - Update to
Registration.
•
Pursuant to s. 63.541, Florida Statutes, information in the registry is confidential and may only be released to:
a) an adoption entity, upon filing of a request for a diligent search of the Florida Putative Father Registry in connection with the planned
adoption of a child,
b) the registrant unmarried biological father upon receipt of a notarized request for a copy of his registry entry and
c) the court, upon issuance of a court order concerning a petitioner acting pro se in an action under this chapter.
•
Florida law requires a fee of $9.00 for filing an indexing a claim of paternity. Please make your check or money order payable to Vital
Statistics. DO NOT SEND CASH. Florida Law imposes an additional service charge of $15 for dishonored checks.
Mail application with payment to VITAL STATISTICS, P.O. BOX 210, Jacksonville, FL 32231-0042
*
http://www.myflorida.com/planning_eval/Vital_Statistics/index.html
***********************************************************************************************************************
OFFICE OF VITAL STATISTICS USE ONLY
ACTUAL NAME OF CHILD
FIRST MIDDLE LAST SUFFIX
DATE OF BIRTH (MM/DD/YYYY) STATE FILE NUMBER
Registration acceptance notice sent to registrant and date sent:
Revocation received date:
Revocation acceptance notice sent to registrant and date sent:
Notice of Termination of Parental Rights - Date received:
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FLORIDA PUTATIVE FATHER REGISTRY CLAIM OF PATERNITY (Duval County Clerk of Courts)

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Completed 9 January 2021

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