DETERMINATION OF PATERNITYTHE INFORMATION ON THIS FORM IS USED TO CREATE A NEW BIRTH CERTIFICATESection 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 Section 3111.01 to 3111.19 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 DATAName of Child from Original Birth Record (First, Middle and Last)Name of Child after Determination of Paternity (First, Middle and Last)Place of Birth (City, County, State)Date of Birth (Month, Day, Year)SexMother's Maiden NameSSN:Mother's Name at Time of the Child=s Birth (First, Middle and Last)FATHER'S PERSONAL DATAALL INFORMATION IS TO BE GIVEN AS OF THE TIME OF THE CHILD'S BIRTHFull Name of FatherSSN:Place of Birth (State or Foreign Country)Date of Birth (Month, Day, Year)Race (American Indian, Black, White, etc.Origin or Descent (Italian. Mexican, German. English, etc.)Of Hispanic Origin? Yes or No (If yes, specify)Usual OccupationKind of Business or industryEducation (Highest Grade Completed)Grades 1-12 or college 1-4 or 5+CERTIFICATIONState of County of I hereby certify that was determined to be the father of the above named child on ,(Father's Name)(Date)Case No. and order the Ohio Department of Health to create a new birth record for this child.CHILD SUPPORT ENFORCEMENT AGENCYCOURT OF DIVISION OF COUNTY OF Administrative Hearing Officer of the AgencyJudge, Magistrate or Deputy ClerkHEA 3029 (Rev. 6/98)2001 © American LegalNet, Inc.INSTRUCTIONS FOR DETERMINATION OF PATERNITYNAME 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.PLACE OF BIRTH (CITY, COUNTY, STATE): Enter City, County or State of the Child's birth.DATE OF BIRTH (MONTH, DAY, YEAR): Enter the Month, Day and Year of the Child's 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 and last name.FULL NAME OF FATHER: Enter the Father's first, middle and last name including suffix (if any).PLACE OF BIRTH (STATE OR FOREIGN COUNTRY): Enter Father's place of birth. 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.KIND OF BUSINESS OR INDUSTRY: Enter Father's type of business or industry, if 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+.2001 © American LegalNet, Inc.