Form Dh 1963 – Fill Out and Use This PDF

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	FIRST		MIDDLE	LAST IINCLUDING ANY SUFFIX	DATE OF BIRTH
REGISTRANT
ADDRESS OF		STREET		CITY	STATE	ZIPCODE
REGISTRANT
PHYSICAL	DESCRIPTION OF FATHER

Part 3 MOTHER'S INFORMATION (If date of birth unknown, provide approximate age of mother)

FULL MAIDEN		FIRST		MIDDLE		MAIDEN SURNAME
NAME OF
MOTHER
LEGAL		LEGAL SURNAME		DATE OF BIRTH
SURNAME OF
MOTHER
ADDRESS OF		STREET		CITY		STATE			ZIP CODE
MOTHER
PHYSICAL DESCRIPTION		OF MOTHER

Part 4 CHILD'S INFORMATION (If exact date of birth unknown, provide estimated date of birth).

FULL

FIRST

MIDDLE

LAST INCLUDING SUFFIX

SEX

NAME OF

CHIL

D

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

1 =

$9.00

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 .

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		FIRST		MIDDLE	LAST (INCLUDING ANY SUFFIX)
	Name
	TYPE OR
	PRINT
DELIVERY ADDRESS (INCLUDE APT. NUMBER, IF			CITY		STATE				ZIP CODE
APPLICABLE)
HOME PHONE NUMBER INCLUDING AREA CODE			WORK PHONE NUMBER INCLUDING				SIGNATURE OF APPLICANT
			AREA CODE
(	)		(	)
					X
IF ATTORNEY or AGENCY, PROVIDE BAR/LICENSENUMBER				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.

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.

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. 409.176 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 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)

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

DH 1963 (Rev. 7/05)