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Get MI DHS-1201 2015-2024

Ld’s Full Name (First, Middle, Last, Suffix) b. Birthdate c. Social Security Number d. Sex (M or F) e. City, County & State of Birth f. Who paid for the birth of child (Medicaid, Private Insurance, Mother, Father, Other)? g. When and where did the mother become pregnant? Date City County State h. Has the father completed a document admitting he is the father of the child, such as an Affidavit of Parentage or is there a court order establishing paternity? If yes, provide the following.

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