DETERMINATION OF PATERNITY
THE INFORMATION ON THIS FORM IS USED TO CREATE A NEW BIRTH CERTIFICATE
Section 3705.09 of the Ohio Revised Code states that when a man is presumed or found to be the father of a child according to Chapter 3111 of the Revised Code or the father has acknowledged the child as his in accordance with former Section 2105.18 and current section 5101.314 of the Revised Code, and documentary evidence of such fact is submitted to the Ohio Department of Health in such form that may be required, a new birth record shall be established.
CHILD'S PERSONAL DATA
Name of Child from Original Birth Record (First, Middle and Last) |
Name of Child after Determination of Paternity (First, Middle and Last) |
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Place of Birth (City, County, State) |
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Date of Birth (Month, Day, Year) |
Sex |
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Mother's Maiden Name |
SSN: |
Mother's Name at Time of the Child’s Birth (First, Middle and Last) |
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FATHER'S PERSONAL DATA
ALL INFORMATION IS TO BE GIVEN AS OF THE TIME OF THE CHILD'S BIRTH
Full Name of Father |
SSN: |
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Place of Birth (State or Foreign Country) |
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Date of Birth (Month, Day, Year) |
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Race (American Indian, Black, White, etc. |
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Origin or Descent (Italian. Mexican, German. English, etc.) |
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Of Hispanic Origin? |
Yes or No (If yes, specify) |
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Usual Occupation |
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Kind of Business or industry |
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Education (Highest Grade Completed)Grades |
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1-12 or college 1-4 or 5+ |
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CERTIFICATION |
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State of ______________________________ |
County of _______________________________ |
I hereby certify that __________________________________________________ was determined to be the father of the above named
(Father's Name)
child on _____________________________, Case No. ________________________ and order the Ohio Department of Health to create
(Date)
a new birth record for this child.
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CHILD SUPPORT ENFORCEMENT AGENCY |
COURT OF __________________________________ |
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COUNTY OF ______________________ |
DIVISION OF ________________________________ |
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__________________________________________ |
_____________________________________________ |
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Administrative Hearing Officer of the Agency |
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Judge, Magistrate or Deputy Clerk |
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HEA 3029 (Rev. 6/98) |
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unknown, enter unknown.
EDUCATION (HIGHEST GRADE COMPLETED) ELEMENTARY OR SECONDARY COLLEGE 1-4 OR 5+: Enter Father's highest grade completed. If high school graduate or GED, enter 12. For college, enter the number of years in college, if 5 years or more enter 5+.
Enter Father's type of business or industry, if
KIND OF BUSINESS OR INDUSTRY:
Include only the State of Foreign Country of birth.
DATE OF BIRTH: Enter the Father's full date of birth including Month, Day and Year.
RACE (AMERICAN INDIAN, BLACK, WHITE, ETC.): Enter the Father's race.
ORIGIN OR DESCENT (ITALIAN, MEXICAN, GERMAN, ENGLISH, CUBAN, PUERTO RICAN, ETC.): List Father's origin or descent, if unknown, enter unknown.
OF HISPANIC ORIGIN? YES OR NO (IF YES, SPECIFY CUBAN, MEXICAN, PUERTO RICAN, ETC.): Enter either NO or YES, if YES specify which origin, if unknown, enter unknown.
USUAL OCCUPATION: Enter Father's usual occupation at the time of the Child's birth, if unknown, enter unknown.
Enter Father's place of birth.
any).
PLACE OF BIRTH (STATE OR FOREIGN COUNTRY):
Enter the Father's first, middle and last name including suffix (if
and last name.
FULL NAME OF FATHER:
birth.
SEX: Enter the sex of the Child at birth.
MOTHER'S MAIDEN NAME: Enter the Mother's first, middle and Maiden last name.
MOTHER'S PRESENT NAME: Enter the Mother's present name including her first, middle
Enter the Month, Day and Year of the Child's
birth.
DATE OF BIRTH (MONTH, DAY, YEAR):
Enter City, County or State of the Child's
PLACE OF BIRTH (CITY, COUNTY, STATE):
INSTRUCTIONS FOR DETERMINATION OF PATERNITY
NAME OF CHILD FROM ORIGINAL BIRTH RECORD: Enter exact spelling of Child's first, middle and last name from original birth certificate.
NAME OF CHILD AFTER DETERMINATION OF PATERNITY: Enter exact spelling of Child's first, middle and last name including suffix (if any e.g. Jr., 11) to be put on the new birth
certificate.
