Ohio Department of Job and Family Services APPLICATION FOR SEARCH OF OHIO PUTATIVE FATHER REGISTRY Ohio Putative Father Registry P.O. Box 182709 Columbus, Ohio 43218-2709 Phone: 1-888-313-3100 Please perform a search of the Ohio Putative Registry. Please advise if a Putative Father Registration form is on file with respect to the mother, child or father identified below. SECTION I: IDENTIFYING INFORMATION ABOUT THE MOTHER FIRST Name Phone Number Race MIDDLE Name Mother's LAST Name Social Security Number Date of Birth (MM/DD/YY) Other names by which mother may be known 1. 2. Home Address City 3. 4. State Zip Code Mother's Mailing Address/Apt. (If different than above) City State Zip Code SECTION II: IDENTIFYING INFORMATION ABOUT THE FATHER Father's LAST Name Social Security Number Date of Birth (MM/DD/YY) Other names by which father may be known 1. 2. Home Address City Father's Mailing Address/Apt. (If different than above) City State Zip Code State FIRST Name Phone Number Race MIDDLE Name 3. 4. Zip Code JFS 01695 (Rev. 3/2008) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com SECTION III: IDENTIFYING INFORMATION ABOUT THE CHILD Child's LAST Name Race Sex Estimated Due Date of Mother (MM/YY) Child's Birthplace Hospital name, if any City Male Child's Date of Birth (MM/DD/YY) State Female FIRST Name MIDDLE Name Birth Certified Yes No Multiple Birth Yes No SECTION IV: INFORMATION ABOUT INTERESTED PARTY REQUESTING SEARCH OF REGISTRY Name of Firm or Agency (if applicable) Name of Person(s) Requesting Search Phone Number Fax Number Person Requesting Search is Attorney Arranging Adoption of Minor Attorney Representing Mother of Minor Mother of Child Private Child Placing Agency (PCPA) or Attorney Representing PCPA Public Children Services Agency (PCSA) or Attorney Representing PCSA Address for Notice of Search Results City State Zip I certify that the information provided in this Search Request Form is true and correct to the best of my knowledge. I further certify that I am requesting this search of the Putative Father Registry to determine whether a putative father is registered in relation to the child referenced above, who is or may be the subject of an adoption petition, and the information obtained will be used for this purpose only. Signature of Individual Requesting Search Date SECTION V: TO BE COMPLETED BY THE OHIO PUTATIVE FATHER REGISTRY Date Request Received (MM/DD/YY) Search Request Record Locator Number Outcome ODJFS Staff JFS 01695 (Rev. 3/2008) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com