LDSS-2725 (Rev. 12/2017)

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

REQUEST/RESPONSE FOR NAME AND/OR ADDRESS

OF FATHER OF CHILD BORN OUT OF WEDLOCK

(Print or type all information)

FORWARD ORIGINALS TO: New York State Office of Children and Family Services (OCFS) Putative Father Registry	REQUEST DATE: / /
REQUEST - (Please: one form per child)
REQUESTING AGENCY/COURT (Name and Address Required):	OCFS, upon request, will provide the names and addresses of persons listed with the registry to any New York State authorized agency or court, and such information shall not be divulged to any other person, except upon order of the court for good cause shown. Social Services Law 372-c Putative Father Registry.
SIGNATURE OF AGENCY/COURT OFFICIAL:	PRINT NAME OF AGENCY/COURT OFFICIAL:	AGENCY/COURT TEL. # (include Area Code): ( )
FATHER’S NAME:	FATHER’S SOCIAL SECURITY # (If known):
MOTHER’S NAME:	MOTHER’S SOCIAL SECURITY # (If known):
CHILD’S NAME:	CHILD’S DATE OF BIRTH: / /

INSTRUCTIONS:
COMPLETE ALL THE BOXES ABOVE. If you complete this form online, print and then sign the form. If you complete a hard copy, please print neatly and sign in the AGENCY/COURT OFFICIAL box.
IF THE MOTHER DOES NOT NAME THE FATHER IN ANY AFFIDAVIT, OR IF THE FATHER’S NAME DOES NOT APPEAR ON THE CHILD’S BIRTH CERTIFICATE, LIST THE FATHER’S NAME AS “UNKNOWN.”
3. MAIL ONLY ONE (1) COPY TO: New York State Office of Children and Family Services NYSAS/Putative Father Registry 52 Washington Street, Room 332 North Rensselaer, NY 12144

OCFS Use Only: Do not write below this line

RESPONSE	Not Registered Registered	Staff InItials:	RESPONSE DATE: / /

REGISTRY INFORMATION
DOCUMENT TYPE: Acknowledgement of Paternity Court Order Instrument to Acknowledge Paternity Notice of Intent to Claim Paternity
PUTATIVE FATHER’S NAME:	DATE OF BIRTH: / /	SOCIAL SECURITY NUMBER:	DATE REGISTERED: / /
ADDRESS:
DATE OF COURT ORDER: / /	DOCKET NUMBER:	COURT: