Parentage Testing CF 5600 Rev 5/06

Child Welfare Parentage Testing and Division of Child Support Notification

BOX 1 - Case Information DHS Case: DHS Contact: Schedule/Reschedule/Redraw: Select One Other: Phone Number: ( ) Ext: Fax: ( ) Branch Name & Address: Mother: SS#: / / City: State: Zip Code: County: DOB: / / Race: Select One DHS/LABCorp Comments: Child: SS#: / / City: State: Zip Code: County: DOB: / / Race: Select One For LabCorp Use Only  Buccal Alleged Father: SS#: / / Drawsite Information City: State: Zip Code: Mother/Child: Appointment Date: ____/____/____ Time: ______County: DOB: / / Race: Select One Drawsite: ______Alleged Father: Appointment Date: ____/____/____ Time: ______Alleged Father: SS#: / / Drawsite: ______City: State: Zip Code: Alleged Father: Appointment Date: ____/____/____ Time: ______County: DOB: / / Race: Select One Drawsite: ______

Box 2 – DCS Notification Notification to DCS of Juvenile Court parentage action Fax to: (503) 986-6289 - Lead worker/ Juvenile contact, State Recovery Central Unit (SRCU) Voluntary acknowledgement attached Certified copy of court order of Paternity or Non-Paternity attached Mail to: Lead worker / Juvenile Contact, State Recovery Central Unit (SRCU),1495 Edgewater Street, NW, Ste 120, Salem, OR 97302 Phone: (503) 986-2501 Box 3 – Authorization and Referral for Parentage Testing Referral to LabCorp - Branch Account #: See page 2 county name & codes Request for Funds Approved by: Referral MUST BE FAXED TO: LabCorp: 1-800-821-9102 and Central Office (503) 378-3800 ______/____/____ Court ordered? Yes No Juvenile Court #: Signature Date

of 2 CF 5600 (6/06) BRANCH ACCOUNT NUMBERS FOR BOX 3 SECTION

BAKER - 36300130" MALHEUR - 36600070 BENTON - 36200155" MARION - Salem - 36200165 CLACKAMAS-Milwaukie - 36101540 MARION - Woodburn - 36230055 CLACKAMAS-Oregon City - 36101545 MORROW - 36700035 CLATSOP - 36101535 MULTNOMAH - East - 36110070 COLUMBIA - 36101565 MULTNOMAH - Gresham - 36100305 COOS - 36400070 MULTNOMAH - Hotline - 36101570 CROOK - 36800075 MULTNOMAH - Midtown - 36100250 CURRY - 36500090 MULTNOMAH - New Market - 36100815 DESCHUTES - 36800030 MULTNOMAH - North/Northeast - 36100255 DOUGLAS - Reedsport - 36101665 MULTNOMAH - Southeast - 36101585 Douglas - Roseburg - 36110090 MULTNOMAH - St. Johns - 36100285 GILLIAM - POLK - 36200135 GRANT - 36700030 SHERMAN - 36101675 HARNEY - 36600055 TILLAMOOK - 36101590 HOOD RIVER - 36101670 UMATILLA - Hermiston - 36700040 JACKSON - 36500100 UMATILLA - Pendleton - 36700025 JEFFERSON - 36800080 UNION - 36101595 JOSEPHINE - 36500080 WALLOWA - 36700020 KLAMATH - 36600060 WASCO - 36101625 LAKE - 36610005 WASHINGTON - Beaverton - 36600050 LANE - Cottage Grove - 36300135 WASHINGTON - Hillsboro - 36101630 LANE - Eugene - 36300140 WASHINGTON - Tigard - 36101640 LANE - Springfield - 36300145 WHEELER - LINCOLN - 36200160 YAMHILL-McMinnville - 36200170" LINN - 36200175 YAMHILL-Newberg - 362001

of 2 CF 5600 (6/06)