FLORIDA PUTATIVE FATHER REGISTRYFLORIDA PUTATIVE FATHER REGISTRY
UPDATE TO CLAIM OF PATERNITYUPDATE TO CLAIM OF PATERNITY
PLEASE READ ENTIRE FORM BEFORE COMPLETING - TYPE OR PRINT CLEARLY
THIS FORM MAY BE USED TO UPDATE REGISTRANT or AGENT/REPRSENTATIVE INFORMATION OR TO FILE A REVOCATION. PLEASE IDENTIFY YOUR PURPOSE BY MARKING THE
APPROPRIATE BOX BELOW YOUR PURPOSE FOR THE UPDATE. YOU MUST COMPLETE PARTS 1 & 3 OF THIS FORM REGARDLESS OF THE PURPOSE FOR FILING. THIS INFORMATION
REQUIRED TO ENABLE US TO LOCATE THE INITIAL REGISTRATION.
Change to Putative Father (Registrant) Information Change to Agent/Representative Information RevocationChange to Putative Father (Registrant) Information Change to Agent/Representative Information Revocation
Part 1 PUTATIVE FATHER'S (REGISTRANT) INFORMATION
FULL NAME OF
REGISTRANT:
FULL NAME OF
REGISTRANT:
FIRSTFIRST MIDDLEMIDDLE LAST INCLUDING ANY
SUFFIX
DATE OF BIRTHDATE OF BIRTH
ADDRESS
INFORMATION
AS CURRENTLY
ON FILE:
RESIDENCE STREET ADDRESS (AND
APT.)
CITY STATE ZIP CODE
NEW
ADDRESS
INFORMATION:
RESIDENCE STREET ADDRESS
(AND APT.)
CITY STATE ZIP CODE
PHYSICAL DESCRIPTION OF FATHER
Part 2 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 representive 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.
AGENT NAME AS
CURRENTLY ON
FILE:
FIRST MIDDLE LAST IINCLUDING ANY
SUFFIX
DATE OF BIRTH
NEW AGENT
FULL NAME:
ADDRESS AS
CURRENTLY ON
FILE:
RESIDENCE STREET ADDRESS (AND
APT.)
CITY STATE ZIP CODE
NEW ADDRESS
INFORMATION:
RESIDENCE STREET ADDRESS (AND
APT.)
CITY STATE ZIP CODE
SIGNATURE OF AGENT OR REPRESENTATIVE
Part 3 Mother / Child Information
FULL NAME OF
MOTHER:
FIRST MIDDLE MAIDEN, IF KNOWN or
LEGAL SURNAME
DATE OF
BIRTH
ADDRESS AS
CURRENTLY ON
FILE:
RESIDENCE STREET ADDRESS
(AND APT.)
CITY STATE ZIP CODE
NEW ADDRESS
INFORMATION:
RESIDENCE STREET ADDRESS
(AND APT.)
CITY STATE ZIP CODE
FULL NAME OF CHILD:
FIRST MIDDLE LAST INCLUDING SUFFIX SEX
CHILD - DATE OF BIRTH
CHILD - CITY OF BIRTH CHILD - COUNTY OF BIRTH CHILD - STATE OF BIRTH
PHYSICAL DESCRIPTION OF MOTHER
Part 4 CONCEPTION INFORMATION
DATE OF CONCEPTION (MONTH, DAY, YEAR)
PLACE AND LOCATION OF CONCEPTION (NOT LIMITED TO, BUT INCLUDING CITY
AND STATE)
Part 5 To provide false information for fraudulent purposes is a third-degree felony punishable by the terms and conditions as set forth in Florida Statutes
SIGNATURE OF APPLICANT
□
Registrant
□
Agent/Representative
DATE SIGNED
Part 6 FATHER'S REVOCATION OF CLAIM OF PATERNITY
This affidavit is filed for purpose of revocation of previous paternity claim made by me. I hereby claim, to the best
of my knowledge, that the birth of the child named above has not occurred. I understand that upon receipt of this
revocation that the claim of paternity previously filed by me and now maintained by the State Office of Vital
Statistics, Florida Department of Health shall be deemed null and void.
_____________________________________________________________________________________
PRINTED NAME OF REGISTRANT
_____________________________________________________________________________________
SIGNATURE OF REGISTRANT
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 NOTARIZING OFFICIAL
(Place Notary Stamp Here)
Mail to Vital Statistics, P. O. Box 210, Jacksonville, Florida 32231-0042
http://www.doh.state.fl.us/planning_eval/vital_statistics/Putative.htm
DH 1964 (Rev. 7/05)
