Interstate Adoption Putative Father Registry Information {NHJB-2190-FP}

THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) INTERSTATE ADOPTION PUTATIVE FATHER REGISTRY INFORMATION 1. Petitioner name(s) 2. Child's birthplace (city/town and state) 3. Is there a putative father's registry in the child's birth state? Yes No 4. If question #3 above is answered yes, please complete the following information and attach the appropriate fees or other requirements in order for the court to process the search request in the other state: Registry or agency name Mailing address Telephone number 5. If question #3 above is answered no, please list the steps you have taken to determine if a registry exists. Date Petitioner Signature Date Petitioner Signature State of This instrument was acknowledged before me on My Commission Expires Affix Seal, if any , County of by Signature of Notarial Officer / Title NHJB-2190-FP (10/01/2006) (formerly AOC-082J-003) Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com