Form Adph Hs 75 – Fill Out and Use This PDF

REQUEST TO ADD FATHER TO CHILD’S ALABAMA BIRTH CERTIFICATE

Please complete this form to add the father’s information to the birth certificate of the child listed below. Before we begin to process your request, additional information and/or documents are needed. Please answer the following questions and provide the documents as indicated when you return this form. After reviewing the information you provide, we will advise you if other documents will be required or if a court action is needed. If you are not a parent of the child or if you do not have legal custody of the child, we may not be able to process your request.

The fee to prepare the new birth certificate is $25 which includes one certified copy of the new birth certificate. Additional copies of the same record ordered at the same time are $6.00 each. Make check or money order payable to “State Board of Health.” Note that fees are not refundable if the action cannot be completed because you did not provide the appropriate legal documents. However, we will return the fee if we determine you are not legally authorized to make the request.

INFORMATION ON PERSON MAKING REQUEST By signing, you are certifying you have a legal right to the record requested. (THIS SECTION MUST BE COMPLETED) Anyone falsely applying for a record is subject to a penalty upon conviction of up to three months in the county jail or a fine of up to $500. Code of Ala. 1975, § 13A-10-109.

Your Signature: ______________________________________________________ Date: __________________________________

Print Your Name: ____________________________________________ Daytime Phone: (______)___________________________

Address: ___________________________________________________________________________________________________

City: ___________________________________________ State: ________________________ Zip Code: _____________________

Your Relationship to Child: _____________________________________________________________________________________

Number of Birth Certificate Copies Requested: _______________________ Fee Enclosed: $________________________________

INFORMATION TO LOCATE CHILD’S BIRTH CERTIFICATE

Full Name of Child as Shown on Birth Certificate: ___________________________________________________________________

Date of Child’s Birth: ______________________________________ County of Child’s Birth: _________________________________

Mother’s Full Maiden Name: ____________________________________________________________________________________

Mother’s Legal Name at Time of Birth: ____________________________________________________________________________

INFORMATION RELATING TO SITUATION AT TIME OF BIRTH

[Needed to determine appropriate legal requirements for making requested change(s) to birth record].

1.	Do you want the father’s name added to the child’s birth certificate?	_______Yes	_______No
2.	Do you want to change the child’s name on the birth certificate when you add the
	father’s name?	_______Yes	_______No
3.	Was the mother married to anyone at the time of the child’s birth, or within 300 days
	before the child’s birth?	_______Yes	_______No
4.	Have the father and mother married since the child was born?
	If Yes, send a certified copy of the marriage certificate.	_______Yes	_______No
5.	Has an individual ever claimed to be the father of this child in court?
	If Yes, send a certified copy of the court order.	_______Yes	_______No
6.	Has the child support court or any other type of court ever declared an individual to
	be the father of this child? If Yes, send a certified copy of the court order.	_______Yes	_______No
7.	Has a court established legal custody for this child?
	If Yes, send a certified copy of the custody order.	_______Yes	_______No
8.	What is the Father’s name, date of birth, and state of birth?

Father’s name:____________________________________________________________________________________

Father’s date of birth: __________________________________ Father’s state of birth: ________________________

MAIL THIS COMPLETED FORM WITH THE APPROPRIATE FEE FOR THE NUMBER OF COPIES REQUESTED TO: Center for Health Statistics

P. O. Box 5625

Montgomery, AL 36103-5625

If you have questions, call a Paternity Specialist at 334. 206.2637. Visit our website at: www.adph.org/vitalrecords

ADPH-HS-75 Rev. 08/2010