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

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FLORIDA PUTATIVE FATHER REGISTRY (Duval County Clerk of Courts)

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FLORIDA PUTATIVE FATHER REGISTRY
APPLICATION FOR SEARCH
CAREFULLY READ the information provided on the reverse of this form. PLEASE TYPE OR PRINT CLEARLY.
Part 1 PUTATIVE FATHER'S (REGISTRANT) INFORMATION (If date of birth unknown, provide approximate age of father)
FULL
NAME OF
REGISTRANT
FIRST MIDDLE LAST IINCLUDING ANY SUFFIX DATE OF BIRTH
ADDRESS OF
REGISTRANT
STREET CITY STATE ZIPCODE
PHYSICAL DESCRIPTION OF FATHER
Part 2 CONCEPTION INFORMATION
DATE OF CONCEPTION (MONTH, DAY, YEAR)
PLACE AND LOCATION OF CONCEPTION (Not limited to, but should include city and state)
Part 3 MOTHER'S INFORMATION (If date of birth unknown, provide approximate age of mother)
FULL MAIDEN
NAME OF
MOTHER
FIRST MIDDLE MAIDEN SURNAME
LEGAL
SURNAME OF
MOTHER
LEGAL SURNAME DATE OF BIRTH
ADDRESS OF
MOTHER
STREET CITY STATE ZIP CODE
PHYSICAL DESCRIPTION OF MOTHER
Part 4 CHILD'S INFORMATION (If exact date of birth unknown, provide estimated date of birth).
FULL
NAME OF
CHIL D
FIRST MIDDLE LAST INCLUDING SUFFIX SEX
DATE OF BIRTH CITY OF BIRTH COUNTY OF BIRTH STATE OF BIRTH
Fees are nonrefundable
Quantity
Amount
$9.00 search fee includes the issuance of a certificate signed by the State Registrar certifying
that:
a) the identity and contact information, if any, for each registered unmarried biological father whose information
matches the search request sufficiently so that such person may be considered a possible father of the subject child;
OR
b) that a diligent search has been made of the registry of registrants who may be the unmarried biological father of
the subject child and that no matching registration has been located in the registry
.
1
=
$9.00
RUSH ORDERS (Optional):
$10.00 additional fee per order. Check box and enter $10.00 in Box if RUSH service desired.
(Refer to information entitled Response Time) Envelope must be marked "RUSH".
Yes
No
$
DH 1963 (Rev. 7/05)
TOTAL AMOUNT ENCLOSED
: Check or money order payable to
Vital Statistics
in U.S. Dollars
(DO NOT SEND CASH)
Florida Law imposes an additional service charge of $15 for dishonored checks
To provide false information or obtain confidential information for fraudulent purposes is a third-degree felony punishable by the terms and conditions as set forth
in Florida Statutes.
APPLICANT NAME/DELIVERY INFORMATION
Applicant's
Name
TYPE OR
PRINT
FIRST MIDDLE LAST (INCLUDING ANY SUFFIX)
DELIVERY ADDRESS (INCLUDE APT. NUMBER, IF
APPLICABLE)
CITY STATE ZIP CODE
HOME PHONE NUMBER INCLUDING AREA CODE
( )
WORK PHONE NUMBER INCLUDING
AREA CODE
( )
SIGNATURE OF APPLICANT
IF ATTORNEY or AGENCY, PROVIDE BAR/LICENSE
NUMBER
IF ATTORNEY, PROVIDE NAME OF PERSON YOU REPRESENT AND THEIR RELATIONSHIP TO
REGISTRANT
IF THE CERTIFICATION IS TO BE MAILED TO ANOTHER PERSON OR ADDRESS USE THE SPACES BELOW TO SPECIFY SHIP TO NAME AND ADDRESS.
SHIP TO NAME
TYPE OR
PRINT
FIRST MIDDLE LAST SUFFIX
HOME PHONE NUMBER
( )
SHIP TO STREET ADDRESS (AND APT.)
WORK PHONE NUMBER
( )
CITY STATE ZIP CODE
NOTE: IF APPLICANT IS THE REGISTRANT (UNMARRIED BIOLOGICAL FATHER), THE AFFIDAVIT
CONTAINED ON THE REVERSE SIDE OF THIS FORM MUST BE COMPLETED AND SIGNED BEFORE A
NOTARIZING OFFICIAL AND THIS APPLICATION MUST BE ACCOMPANIED BY PICTURE IDENTIFICATION.
$
X
Print Form
Clear Form
DH 1963 (Rev. 7/05)
INFORMATION AND INSTRUCTIONS FOR FLORIDA PUTATIVE FATHER SEARCH
This form is to be used
only
when a search of the Putative Father Registry is requested.
DO NOT
use to file a Claim
of Paternity. Use Claim of Paternity, DH Form 1965 for filing with the Florida Putative Father Registry.
NOTE: To enable us to conduct a thorough search, it is important that you provide as much information as known to you regarding the
putative father, mother and child.
ELIGIBILITY: All information contained in the Florida Putative Father Registry is confidential and exempt from public disclosure.
Information from the registry shall only be disclosed to:
a)
An adoption entity in connection with the planned adoption of a child.
b)
The registrant unmarried biological father, upon receipt of his notarized request.
c)
The court, upon issuance of a court order concerning a petitioner acting pro se in an action under this
chapter.
"Adoption Entity" as defined in s. 63.032(3), Florida Statutes, means the department, an agency, a child-caring agency registered under s.
409.1
76 Florida Statutes, an intermediary, or a child-placing agency licensed in another state which is qualified by the department to place
children in the State of Florida.
"Department" as defined in 63.032(8), Florida Statutes, means the Department of Children and Family
Services.
"Agency" as defined in 63.032(5), Florida Statutes, means any child-placing agency licensed by the department pursuant to s. 63.202 to
place minors for adoption.
"Intermediary" as defined in 63.032(9), Florida Statutes, means an attorney who is licensed or authorized to practice in this state and who
is placing or intends to place a child for adoption, including placing children born in another state with citizens of this state or country or
placing children born in this state with citizens of another state or country.
RESPONSE TIME:
Response time for processing a request varies depending upon our workload at the time your request is received.
Generally, a request is completed within five work days. RUSH processing is available for those who need assurance of faster service. Orders
received in an envelope marked RUSH and with the $10.00 RUSH fee will be given priority over other pending work; however, no certification
can be issued until all requirements, forms, applicable fees and appropriate signatures have been received and meet the criteria as established by
law or in rules of the department.
To be used only when the applicant is a Putative Father who has filed a Claim of Paternity
NOTARIZED AFFIDAVIT OF PUTATIVE FATHER (REGISTRANT UNMARRIED BIOLOGICAL FATHER)
I do swear or affirm that I am the registrant and request search of the Florida
Putative Father Registry for a copy of my registry entry. I have attached a copy of
photo identification.
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: DEPARTMENT OF HEALTH, VITAL STATISTICS, P.O. BOX 210, Jacksonville, FL 32231-0042
http://www.doh.state.fl.us/planning_eval/vital_statistics/Putative.htm
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FLORIDA PUTATIVE FATHER REGISTRY (Duval County Clerk of Courts)

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Completed 9 January 2021

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