FLORIDA PUTATIVE FATHER REGISTRY

CLAIM OF PATERNITY
CAREFULLY READ the information provided on the reverse of this form. PLEASE TYPE OR PRINT CLEARLY.
Part 1 PUTATIVE FATHER’S (REGISTRANT) INFORMATION TO BE INCLUDED IN PUTATIVE FATHER REGISTRY
FIRST MIDDLE LAST INCLUDING ANY SUFFIX DATE OF BIRTH
FULL NAME OF
FATHER

RESIDENCE STREET ADDRESS (AND APT.) CITY STATE ZIP CODE

ALTERNATE/PHYSICAL ADDRESS (AND APT.), IF APPLICABLE CITY STATE ZIP CODE

DAYTIME TELEPHONE (INCLUDING AREA CODE) CELL PHONE NUMBER FAX NUMBER

PHYSICAL DESCRIPTION OF FATHER

Part 2 CONCEPTION INFORMATION

DATE OF CONCEPTION (MONTH, DAY, YEAR) PLACE AND LOCATION OF CONCEPTION (Not limited to, but including city and state)

Part 3 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 representative 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.
PRINTED FULL NAME OF FIRST MIDDLE LAST SUFFIX
AGENT OR
REPRESENTATIVE

RESIDENCE STREET ADDRESS (AND APT.) CITY STATE ZIP CODE

SIGNATURE OF AGENT OR REPRESENTATIVE

DAYTIME TELEPHONE (INCLUDING AREA CODE) CELL NUMBER FAX NUMBER

Part 4 MOTHER’S INFORMATION (If date of birth unknown, provide approximate age of mother)
FIRST MIDDLE LAST, MAIDEN OR LEGAL DATE OF BIRTH
FULL NAME OF
MOTHER

RESIDENCE STREET ADDRESS (AND APT.) CITY STATE ZIP CODE

PHYSICAL DESCRIPTION OF MOTHER

Part 5 CHILD’S INFORMATION (If date of birth unknown, provide estimated date OR anticipated date of delivery in case where birth has not yet occurred).
FIRST MIDDLE LAST INCLUDING SUFFIX SEX
FULL NAME OF
CHILD

DATE OF BIRTH CITY OF BIRTH COUNTY OF BIRTH STATE OF BIRTH

FEE FOR FILING & INDEXING YOUR CLAIM OF PATERNITY IN THE FLORIDA PUTATIVE FATHER REGISTRY
Check or money order payable to Vital Statistics in U.S. Dollars (DO NOT SEND CASH) $9.00

PUTATIVE FATHER’S ACKNOWLEDGMENT

To provide false information for fraudulent purposes is a third-degree felony punishable by the terms and conditions as set forth in Florida Statutes
I hereby swear or affirm to the best of my knowledge and belief that I am the biological father of the child referenced above
and submit to and will pay for DNA testing, if requested, as provided by law. I understand this information will be
included in the Florida Putative Father Registry and by filing this claim of paternity I am confirming my willingness and Personally Known or Provided ID
intent to support the child referenced above in accordance with state law.
_______________________________________________________________________________________
PRINTED NAME OF PUTATIVE FATHER Type of Identification Produced
_______________________________________________________________________________________
SIGNATURE OF PUTATIVE FATHER

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)

DH 1965 (07/2012)
64V-1.016(1), Florida Administrative Code
 IMPORTANT INFORMATION CONCERNING
FLORIDA PUTATIVE FATHER REGISTRY - CLAIM OF PATERNITY
BACKGROUND AND PURPOSE Section 63.054, Florida Statutes has provided for the establishment of a Putative Father Registry in the Office
of Vital Statistics (OVS), Florida Department of Health (DOH). The purpose of the registry is to permit a man alleging to be the biological father of
a child to assert his parentage, independent of the mother, and preserve his rights as a parent. This registry also may expedite adoptions of children
whose biological fathers are unwilling to assume responsibility of their child. For purposes of this provision registrant means an “unmarried
biological father”. If an unmarried biological father fails to take the actions that are available to him to establish a relationship with his child, his
parental interest may be lost entirely, or greatly diminished, by his failure to timely comply with the available legal steps to substantiate a parental
interest. Chapter 63, Florida Statutes governs adoption proceedings in Florida. Visit: http://www.leg.state.fl.us/statutes/index.cfm

A man is presumed to be the biological father if:

 The minor was conceived or born while the father was married to the mother;
 The minor is his child by adoption;
 The minor has been adjudicated by the court be his child, by the date a petition is filed for termination of parental rights.
 He has filed an affidavit of paternity by acknowledging paternity in conjunction with the child’s mother at the hospital at the time of child’s
birth or by subsequently filing an acknowledgment of paternity in conjunction with the child’s mother with the Bureau of Vital Statistics
both of which constitutes the establishment of paternity as provided for in section 742.10, Florida Statutes, by the date a petition is filed for
termination of parental rights.
The information provided herein is not designed to be legal advice. Questions concerning paternity, presumption of paternity, or rights and responsibilities of
a parent should be directed to an attorney.

INFORMATION FOR COMPLETING CLAIM OF PATERNITY FORM - Type or print neatly. This form MUST be signed under oath.
 All information in Part 1 concerning the father is required. Do not leave any of these items blank.
 Complete Parts 2, 4 & 5 to the best of your ability. The child’s name, date of birth, place of birth, and the mother’s maiden name are
critical to linking the Claim of Paternity with an actual child. The more complete the information you provide, the more effective the
paternity registry can be. If mother’s maiden name is unknown but her legal surname is known, please provide legal surname and indicate
that name provided is legal surname. If you have named an agent/representative to act on your behalf, said agent or representative MUST
file an acceptance of the designation, in writing, in order to receive notice or service of process.
 A Claim of Paternity may be filed any time prior to the birth BUT a claim of paternity may not be filed after the date a petition is filed for
termination of parental rights.
 By filing this claim of paternity, the registrant expressly consents to submit and pay for DNA testing upon the request of any party, the
registrant, or the adoption entity with respect to the child referenced in the claim of paternity.
 The registrant may, at any time prior to the birth of the child for whom paternity is claimed, execute a notarized written revocation of the
claim of paternity previously filed and upon such revocation, the claim of paternity shall be deemed null and void. A Claim of Paternity -
Update to Registration form is available for this purpose.
 If the court determines that a registrant is not the father of the minor, the court shall order the department to remove the registrant’s name
from the registry.
 It is the obligation of the registrant or, if designated an agent or representative, to notify and update the information contained in the
registry in OVS of any change of address or change in the designation of an agent or representative. A Claim of Paternity - Update to
Registration form is available for this purpose.
 OVS will notify the registrant, in writing, of their receipt of a Claim of Paternity OR a Revocation filed on a Claim of Paternity - Update to
Registration.
 Pursuant to s. 63.541, Florida Statutes, information in the registry is confidential and may only be released to:
a) an adoption entity, upon filing of a request for a diligent search of the Florida Putative Father Registry in connection with the planned
adoption of a child,
b) the registrant unmarried biological father upon receipt of a notarized request for a copy of his registry entry,
c) the birth mother, upon receipt of a notarized request for a copy of any registry entry in which she is identified as the birth mother,
d) the court, upon issuance of a court order concerning a petitioner acting pro se in an action under this chapter.

 Florida law requires a fee of $9.00 for filing an indexing a claim of paternity. Please make your check or money order payable to Vital
Statistics. DO NOT SEND CASH. Florida Law imposes an additional service charge of $15 for dishonored checks.

Mail Claim of Paternity with payment to VITAL STATISTICS, P.O. BOX 210, Jacksonville, FL 32231-0042
Visit our website at: http://www.doh.state.fl.us/planning_eval/vital_statistics/Putative.htm
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OFFICE OF VITAL STATISTICS USE ONLY
FIRST MIDDLE LAST SUFFIX
ACTUAL NAME OF
CHILD
DATE OF BIRTH (MM/DD/YYYY) STATE FILE NUMBER
Registration acceptance notice sent to registrant and date sent:
Revocation received date:
Revocation acceptance notice sent to registrant and date sent:
Notice of Termination of Parental Rights – Date received:

DH 1965 (07/2012)
64V-1.016(1), Florida Administrative Code