Registration Form for Putative Fathers:
After you have
completed this form, you must sign it electronically by typing your name in the
certification box, and submit it to the Putative Father Registry by clicking on
the "Submit" box. The Putative Father Registry must receive the registration
before it will be considered filed and the Certification of Registration can be
issued.
No one is allowed to register on behalf of a putative father!
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| Name |
|
|
|
| |
First
* |
Middle |
Last
* |
| Other name/s by which you may be known:
|
| Address:* |
Apt:
County:*
|
| City:* |
State:*
Country:*
Zip Code:
*
|
| Mailing Address (if different than residence) |
| Address: |
Apt:
County:
|
| City: |
State:
Country:
Zip Code:
|
| Phone Number(s): |
(1)*
-
-
|
(2)
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-
|
| Previous Address in last year |
| Address: |
Apt:
County:
|
| City: |
State:
Country:
Zip Code:
|
| Employer's Information |
| Name |
|
Phone |
| Address |
|
| City: |
State:
Country:
Zip Code:
|
| |
| Social Security Number
* |
-
-
|
Date of Birth
* |
| Physical Description |
| Race
*
Height
*
ft.
in. Weight
*
lbs.
|
| Hair
*
Eyes
*
|
| |
| Information About The Mother (Please
complete as much as possible) |
| Name |
|
|
|
| |
First |
Middle |
Last |
| Maiden Name |
Other name/s by which the mother may be known:
|
| Address: |
Apt:
County:
|
| City: |
State:
Country:
Zip Code:
|
| Mailing Address (if different than residence) |
| Address: |
Apt:
County:
|
| City: |
State:
Country:
Zip Code:
|
| Phone Number(s): |
(1) |
(2) |
|
| Employer's Information |
| Name |
|
Phone |
| Address |
|
| City: |
State:
Country:
Zip Code:
|
| |
| Social Security Number
Date of Birth
Estimated Age
|
| Physical Description |
| Race
Height
ft.
in. Weight
lbs. |
| Hair
Eyes
|
| |
| Information About Child (Please complete as
much as possible) |
| Name |
|
|
|
| |
First |
Middle |
Last |
| Other Names: |
|
Nicknames: |
| Sex:
|
DOB
|
Estimated Due Date of Mother
|
| Child's Place of Birth |
Hospital Name:
|
| City: |
State:
County:
Country:
|
| |
Has a court in Illinois or another state or territory of the
United States ruled that you are the father of the child referenced here?
If the answer to this question is yes, please attach a certified copy of the
court order.
|
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I understand that filing with the Putative Father Registry is only the first
step in protecting my interests in being considered the legal father of the
child and that I will have the right to object to an adoption only if I start
legal proceedings to establish that I am the father. It is called a parentage
action and must be completed with in 30 days of the date of my registration
with the Putative Father Registry. For assistance with starting a parentage
action, I must contact the Illinois Department of Public Aid. In Cook County
contact the Division of Child Support Services at 36 S Wabash, 9th floor Chicago, IL 60603.
For information to proceed in all counties,
including Cook, I am to call 1-800-447-4278. There is a small fee that may be
waived if I cannot afford it.
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I understand that I must inform the Putative Father Registry if I change my
address or if any other information changes on this form so that I can be
located if the child I have identified becomes the subject of an adoption
proceeding.
-
Attention! It is necessary to
print this completed form and the Putative Father Registry Certification of
Registration and keep for your records.
I have read, or someone has read to me, the information above before signing
this form, and I understand that completing this form is not enough to protect
my right to be the legal father of the child identified on this form.
Typing your name in the box below, is equivalent to signing the document.
Signature of Father:
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