PROBATE COURT OF SHELBY COUNTY, OHIO WILLIAM R. ZIMMERMAN, JUDGE PLACEMENT OF (Name before placement) CASE NO. AFFIDAVIT REGARDING BIRTH FATHER The following statements are made to the best of my knowledge regarding the child for which approval of placement for adoption is sought in the within case. [Check and complete whichever of the following are applicable]: [ ] I have not filed proceedings under Sections 3111.01 to 3111.19 of the Ohio Revised Code or any administrative proceedings pursuant to Sections 3111.20 to 3111.29 of the Ohio Revised Code against any male person at any time before the placement of the child in the home of the adoptive parents. [ ] No male person has acknowledged the paternity of the child in any court of competent jurisdiction or in any administrative proceeding. [ ] No male person has signed the birth certificate as an informant as provided in Section 3705.14 of the Ohio Revised Code. [ ] The identity of the father is unknown. [ ] The father is whose residence address is [ ] The putative father is whose residence address is Birth Mother Sworn to before me and signed in my presence this in , day of . Notary Public H.C. FORM 118.22 - AFFIDAVIT REGARDING BIRTH FATHER 02/10/03 American LegalNet, Inc. www.FormsWorkflow.com