Form 1 Required and Optional Data Elements

Table 1: Complete List of Required and Optional Data Elements

REQUIRED DATA ELEMENTS

OPTIONAL DATA ELEMENTS

1. Current Full Name

1. Daytime Phone Number

(mother, father and child)

(mother and father)

2. Social Security Number

2. Birthplace - mother and father

(mother and father)

(city, county & state)

3. Date of Birth

3. Hospital of Birth

(mother, father and child)

(child)

4. Address
(mother and father)

4. Sex of Child

5. Birthplace - child
(city, county & state)

5. Father's Employer

6. Legal Finding (60 day rescission)

6. Ethnicity of Father

7. Rights and Responsibilities,
Alternatives and Consequences

7. Medical Insurance

8. Signature Lines for Parents

8. Maiden Name of Mother

9. Notary Seals/Witnesses: Signature
Lines

9. Place Where Acknowledgment or Affidavit Was Completed
10. Offer of Name Change
(child)
11. Minors: Signature Line for Guardian Ad Litem or Legal
Guardian
12. Three-Way Signature Offered on Form
(husband, wife, and biological father)
13. An advisory to parents that they may wish to seek legal
counsel or obtain a genetic test before signing
14. A statement concerning the custody status of the child visa-vis State law

OMB Control Number: 0970-0171
Expiration Date: 05/31/2017
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)
Public reporting burden for this collection of information is estimated to
average 1 hour per response, including the time for reviewing instructions,
gathering and maintaining the data needed, and reviewing the collection of
information.
An agency may not conduct or sponsor, and a person is not required to respond
to, a collection of information unless it displays a currently valid OMB control
number.