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ON TO BE INCLUDED IN PUTATIVE FATHER REGISTRY FIRST MIDDLE LAST INCLUDING ANY SUFFIX DATE OF BIRTH RESIDENCE STREET ADDRESS (AND APT.) CITY STATE ZIP CODE ALTERNATE/PHYSICAL ADDRESS (AND APT.), IF APPLICABLE CITY STATE ZIP CODE DAYTIME TELEPHONE (INCLUDING AREA CODE) CELL PHONE NUMBER FAX NUMBER FULL NAME OF FATHER PHYSICAL DESCRIPTION OF FATHER Part 2 CONCEPTION INFORMATION DATE OF CONCEPTION (MONTH, DAY, YEAR) PLACE AND LOCATION OF CONCEPTION (Not limited to, but including ci.

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