Notification Of Order Of Parentage And Application For A New Birth Certificate {JC-170}

STATE OF TENNESSEE TENNESSEE DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS NOTIFICATION OF ORDER OF PARENTAGE AND APPLICATION FOR A NEW BIRTH CERTIFICATE TENNESSEE CODE ANNOTATED § 36-2-113 AND 68-3-310 Name of Court: __________________________________________ County: _________________________________________ Date: ____________________________________________ State: _________________________________________________ Docket Number: _____________________________________ Date of Decree: ______________________________________ SECTION I INFORMATION CONCERNING CHILD Name of Child Prior to Court Order: ______________________________________ Social Security Number:________________ Date of Birth: ___________________ Place of Birth: ________________________________________________ Sex: ________ (CITY) (COUNTY) (STATE) SECTION II (FIRST) INFORMATION FOR NEW CERTIFICATE OF BIRTH (MIDDLE) (LAST) Name of Child: ___________________________________________________________________________________________ As Determined by Court FATHER OF CHILD Full Name: ___________________________________________ Date of Birth: _________________________________________ Birthplace: ___________________________________________ (STATE OR FOREIGN COUNTRY) MOTHER OF CHILD Full Legal Name: ___________________________________ Full Maiden Name: __________________________________ Date of Birth: ______________________________________ Residential Address: _________________________________ __________________________________________________ (CITY) (COUNTY) (STATE) (ZIP CODE) Residential Address: ___________________________________ ____________________________________________________ (CITY) (STATE) (ZIP CODE) Mailing Address (if different): ____________________________ Mailing Address (if different): __________________________ ( ) Home Telephone Number: ______________________________ Social Security Number: ________________________________ Driver's License Number: _______________________________ Employer: ____________________________________________ Employer's Address: ____________________________________ ( ) Home Telephone Number: ____________________________ Social Security Number: _____________________________ Driver's License Number: _____________________________ Employer: _________________________________________ Employer's Address: ________________________________ Employer's Telephone Number: _______________________ Health Insurance: ___________________________________ Policy Number: _____________________________________ ( ) Employer's Telephone Number: __________________________ Health Insurance: ______________________________________ Policy Number: _______________________________________ INSTRUCTIONS ( ) 1. A new certificate of birth will be prepared in accordance with the law upon the completion and submission of this form and a certified copy of the court's order of parentage. 2. Enclose the $27.00 fee required for preparation and issuance of a new birth certificate. Make check payable to Tennessee Vital Records. 3. Mail to: TENNESSEE VITAL RECORDS 421 5TH AVENUE NORTH 1ST FLOOR, CENTRAL SERVICES BLDG 6/15/03 JC-170 NASHVILLE, TN 37247-0450 IV-D Approved American LegalNet, Inc. www.FormsWorkFlow.com