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  1.   What is your relationship to the child you are seeking to establish paternity for (i.e. natural father, other)?


  2.   If other, please explain.__________________________________

  3.   Please state the full legal name of the child you would like to establish paternity for?


  4.   What is the child’s date of birth? ___________________________

  5.   In what city, county, and state was the child born?

       City: ________________ County: ______________ St: ____

  6.   Do you remember the date the child’s mother got pregnant? ____ (yes or no)

  7.   If so, what was the month and year? __ __ __ (mmddyy)

  8.   Did her pregnancy go the full term? ____ (yes or no)

  9.   If no, please explain why (i.e. premature)?

 10.   Do you remember the city, county, and state you were in when she got pregnant?___ (yes or no)

 11.   In what city, county state did she get pregnant?

       City: ________________ County: ______________ St: ____

 12.   What is the child’s mother’s maiden name? _______________________________________________

 13.   Please state the full legal name of the woman you conceived this child with?

       First:_______________________ Mid Initial:______ Last: ______________________________

 14.   Did you live together? ____ (yes or no)

 15.   If so, from what date to what date. _________________________________________________

 16.   Which city, county, or state?

       City: ________________ County: ______________ St: ____

 17.   Did she ever tell you that you were the father of this child? ____ (yes or no)

 18.   Did she ever admit that you were the father of this child? ____ (yes or no)

 19.   Are you named the father on the child’s birth certificate? ___ (yes or no)

 20.   If so, can you provide us a copy of the birth certificate? ____ (yes or no)

 21.   Did you ever sign an acknowledgement of paternity? ____ (yes or no)
22.   If so, can you provide us with a copy of the acknowledgement? ____ (yes or no)

23.   Were you present at the child birth? ____ (yes or no)

24.   Did you visit the child at the hospital following the birth? ____ (yes or no)

25.   If so, did you sign an acknowledgement of paternity at the hospital? ____ (yes or no)

26.   Did you ever offer to pay abortion expenses? ____ (yes or no)

27.   Did you ever offer to pay medical expenses? ____ (yes or no)

28.   Did you pay for birth related expenses? ____ (yes or no)

29.   Did you ever claim the child on your tax returns? ____ (yes or no)

30.   Have you ever provided food, clothing, gifts, or financial support for this child?____ (yes or no)

31.   Please describe these food, items, or type of financial support.___________________________

32.   Did you ever live with this child? ____ (yes or no)

33.   Please describe where and when you lived with child.

      City: ________________ County: ______________ St: ____ Dates: _______________ (from/to)

34.   Did you ever visit the child? ____ (yes or no)

35.   What were the dates and circumstances of any visits between you and the child.



36.   Does the child resemble you? ____ (yes or no)

37.   Please describe any physical resemblance between you and the child.



38.   Do you have any photos you can leave with us? ____ (yes or no)

39.   Are there any witnesses to your relationship with the child’s mother? ____ (yes or no)

40.   If so, what are the names and addresses of these people?



41.   What might be some relevant facts known by each of these people?



42.   Are you employed? ______ (yes or no)
43.   If so, where? __________________________________________________________________

44.   How many hours do you work?______________________________

45.   What is your hourly wage? _________________________________

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