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DPHHS -CFS -096 State of Montana (Rev. 9/17) Department of Public Health and Human Services Putative Father Registration (Effective October 1, 1998) INSTRUCTIONS : Please print or type the following information, which is confidential except as provided by law. Your full legal name: Social Security Number: Birth Date: If you are an Indian, what is your tribal affiliation: Address at which you want legal notices to be sent: If above address is not your address, name of the person at this address to whom the notice should be sent: Legal name of the mother of the child: Any other names she may use: Her Social Security Number, if known: Her birth date, if known: Her address, if known: Child’s name, if known: Location (City/State) of child’s birth, if known: Location (City/State) and date of possible conception of child: If your address changes, it is your responsibility to update the Vital Statistics Bureau with a current address at which you will receive legal notices. This form may be mailed, faxed or delivered to the Vital Statistics Bureau, Department of Public Health and Human Services, PO Box 4210, 111 N Sanders, Room 6, Helena, MT 59601, FAX (406) 444- 1803. If you want to protect your right to receive notice of a hearing regarding your child, submit this form promptly. The form must be RECEIVED not later than 72 hours after the birth of the child. If you fail to register for a specific child within 72 hours of the birth of that child, you may lose all parental rights to that child. You may file with the registry even though you have no actual knowledge that a pregnancy has occurred or a child has been born. Information provided to the registry may be used for purposes of establishing a child support obligation. Verificati on of Signer's ID is Mandatory State of: ____________ County of: _______________ Signed______________________________________ This document was signed and sworn to (or affirmed) before me o n by Date Name of Signer [Official Seal] (Notary's Signature)