Determination of Paternity - Fairfield County Court of Common Pleas (Fillable)

Name of Child from Original Birth Record (First, Middle and Last) Name of Child after Determination of Paternity (First, Middle and Last) Place of Birth (City, County, State) Date of Birth (Month, Day, Year) Sex Mother's Maiden Name Mother's Social Security Number Mother's Name at Time of the Child's Birth (First, Middle and Last) Full Name of Father Father's Social Security Number Place of Birth (State or Foreign Country) Father's Date of Birth (Month, Day, Year) Race (American Indian, Black, White, etc.) Origin or Descent (Italian, Mexican, German, English, etc.) Of Hispanic Origin? Yes or No (If yes, specify) Usual Occupation Kind of Business or Industry Education (Highest Grade Completed) Grades 1-12 or college 1-4 or 5+ Father's Name in Certification Section Date Case Number County of Child Support Enforcement Agency Administrative Hearing Officer of the Agency signature or name Judge, Magistrate or Deputy Clerk signature or name