Free 53702.FH11 - Indiana

VERIFICATION OF BIRTH
State Form 53702 (9-08) / BCC 0216

Reset Form

Please complete one form per family. This form must be kept on file at the licensed child care program. I, ________________________________________________, have viewed the birth certificates of the child(ren) listed and attest the name(s) and date(s) of
Name of child care provider employee

birth of the child(ren) listed below are accurate according to the Division of Family Resources pursuant to IC 12-17.2-2-1.5.
Full name of child City and state of birth Name(s) of mother and/or father Signature of provider Date birth certificate viewed (month, day, year) Birth certificate number Date of birth (month, day, year) Date of issue (month, day, year)

Full name of child City and state of birth Name(s) of mother and/or father Signature of provider Birth certificate number

Date of birth (month, day, year) Date of issue (month, day, year)

Date birth certificate viewed (month, day, year)

Full name of child City and state of birth Name(s) of mother and/or father Signature of provider Birth certificate number

Date of birth (month, day, year) Date of issue (month, day, year)

Date birth certificate viewed (month, day, year)

Full name of child City and state of birth Name(s) of mother and/or father Signature of provider Birth certificate number

Date of birth (month, day, year) Date of issue (month, day, year)

Date birth certificate viewed (month, day, year)

Full name of child City and state of birth Name(s) of mother and/or father Signature of provider Birth certificate number

Date of birth (month, day, year) Date of issue (month, day, year)

Date birth certificate viewed (month, day, year)

Full name of child City and state of birth Name(s) of mother and/or father Signature of provider Birth certificate number

Date of birth (month, day, year) Date of issue (month, day, year)

Date birth certificate viewed (month, day, year)