Print Form Request for Notice to Putative Father Clear Form (Rev. 10/05/07) CCCO 0024 IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, COUNTY DIVISION IN THE MATTER OF NOTICE TO ________________________________________________ PUTATIVE FATHER ________________________________________________ (Street) ________________________________________________ (City) (State) (Zip) } No. _________________________________ REQUEST FOR NOTICE TO PUTATIVE FATHER (0029) _________________________________________ states: The undersigned, in accordance with 750 ILCS 50/12a, of the Illinois Adoption Act, requests a notice to be sent to: ________________________________________________________________________________________ named as the father of a child born on the ________________ day ___________________________, ____________ or expected to be born on or about the _______________ day of ___________________________, _____________. The mother of said child is _______________________________________________________________________ ____________________________________________ VERIFICATION BY CERTIFICATION Under penalties as provided by law pursuant to 735 ILCS 5/1-109 I certify that the statements set forth in the Request for Notice and Affidavit for Father Identification are true and correct, except as to matters therein stated to be on information and belief, and as to such matters, I certify that I believe the same to be true. ___________________________________________ Signature ____________________________________________ Date DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS