Register as a Putative Father
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Instructions:
  • After completing the application below, you will be asked to print it, sign it and mail it to the Virginia Department of Social Services, 801 E. Main Street, Richmond, VA 23229 in order to complete the process.
  • Questions or comments may be directed by phone to (877) 433-2339 or by e-mail to PutativeFather@dss.virginia.gov
  • * Indicates a required field

Type of Registration

Q01. *This is a(an):

New registration
Update of a previously submitted registration
Withdraw a previously submitted registration.

Putative Father's Identifying Information

Q02. Name:

*First:
 Middle:
*Last:
 Also known as:

Q03. *DOB: / /

Q04. *Social Security #: --
(Section 63.2-1251, Code of Virginia requires the submission of the social security number.)

Q05. Driver's license information:

License #:
State:

Q06. State ID #:

Q07. Proof of legal residency:

Type:
Number:

Q08. Permanent home address:

*Street:
*City:
*State:
*Zip:

Q09. Current mailing address:

Street (or P.O.):
City:
State:
Zip:

Q10. *Phone: () -

Q11. E-mail:

Q12. Employer:

Q13. Occupation:

Q14. Ethnicity:

Q15. Race:

a) White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
b) Black or African American. A person having origins in any of the black racial groups of Africa.
c) Hispanic (includes persons of Mexican, Puerto Rican, Central or South American or other Spanish origin or culture)
d) Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent.
e) American Indian or Alaskan Native. A person having origins in any of the original peoples of North, Central, or South America, and who maintains tribal affiliation or community attachment.
f) Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Q16. Physical description:

a) Height: Feet Inches
b) Weight: Pounds
c) Hair color:
d) Eye color:
e) Identifying marks:

Q17.Location/Date(s) where child was conceived:

a) *State:
b) *City:
c) *Date(s): / /  -  / /

Mother's Identifying Information (if known)

Q18. Name:

First:
Middle:
Last:
Also known as:

Q19. DOB: / /

Q20. Approximate age:

Q21. Permanent home address:

Street:
City:
State:
Zip:

Q22. Current mailing address:

Street (or P.O.):
City:
State:
Zip:

Q22. Phone: () -

Q23. E-mail:

Q24. Employer:

Q25. Occupation:

Q26. Ethnicity:

Q27. Race:

a) White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
b) Black or African American. A person having origins in any of the black racial groups of Africa.
c) Hispanic (includes persons of Mexican, Puerto Rican, Central or South American or other Spanish origin or culture)
d) Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent.
e) American Indian or Alaskan Native. A person having origins in any of the original peoples of North, Central, or South America, and who maintains tribal affiliation or community attachment.
f) Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Q28. Physical description:

a) Height: Feet Inches
b) Weight: Pounds
c) Hair color:
d) Eye color:
e) Identifying marks:

Child's Identifying Information (if known)

Q29. Name:

First:
Middle:
Last:
Also known as:

Q30. DOB: / /

Q31. Gender:

Male
Female

Q32. Place of birth:

a) City:
b) State:
c) Hospital:

Q33. Estimated due date of mother: / /


(Form # 032-02-0500-00-eng)