Data Elements

Table 1: Complete List of Required and Optional Data Elements
REQUIRED DATA ELEMENTS

OPTIONAL DATA ELEMENTS

1. Current Full Name
(mother, father and child)

1. Daytime Phone Number
(mother and father)

2. Social Security Number
(mother and father)

2. Birthplace - mother and father
(city, county & state)

3. Date of Birth
(mother, father and child)

3. Hospital of Birth
(child)

4. Address
(mother and father)

4. Gender 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 vis-a-vis State law

Expiration Date: January 31, 2021

OMB Control Number: 0970-0171