15-Attachment 5 - Customer Authorization and Chain of Custody Form.pdf

ATTACHMENT 5

Authorization and Chain of Custody Forms

Page 1 of 3 Attachment 5 Paternity Testing Services RFP 3/26/2020

**NOTE: Forms are subject to change**

Acct #:

Account’s Case # Docket/Court # Cause #

List all Parties M

C

C

AF

SEND ADDITIONAL RESULT COPIES TO:

Specimen # MOTHER

Last Name: First Name: MI:

Date of Birth:

Ethnicity: Caucasian Black Puerto Rican Mexican American American Indian (Tribe)

Asian (Specify Country) Other (Specify) Mix (Specify race and %)

Blood Transfusion in the past 90 days: Yes / No Have you ever had a bone marrow/stem cell transplant (circle one): Yes / No

Y ___ L ___ B ___ C___ Last 3 digits of Mother’s ID # & Type:

Specimen # CHILD Last Name: First Name: MI:

Date of Birth: Sex:

Blood Transfusion in the past 90 days(check one): Yes/ No Have you ever had a bone marrow/stem cell transplant (check one): Yes/ No

Y ___ L ___ B ___ C___ Last 3 digits of Child’s ID # & Type:

Specimen # ALLEGED FATHER

Last Name: First Name: MI:

Date of Birth:

Ethnicity: Caucasian Black Puerto Rican Mexican American American Indian (Tribe)

Asian (Specify Country) Other (Specify) Mix (Specify race and %)

Blood Transfusion in the past 90 days(check one): Yes/ No Have you ever had a bone marrow/stem cell transplant (check one): Yes/ No

Y ___ L ___ B ___ C___ Last 3 digits of Father’s ID # & Type:

Texas Office of the Attorney General, Child Support Division

INTRA –

STREET ADDRESS

CITY, TX ZIP CODE

(PHONE #)

Page 2 of 3 Attachment 5 Paternity Testing Services RFP 3/26/2020

**NOTE: Forms are subject to change**

MOTHER’S / CHILD’S PHOTOGRAPH

DO NOT PLACE PHOTO BELOW THIS LINE

I submit myself for sample collection and testing for paternity evaluation.

Print Mother’s Name:

Mother’s Signature: ______________________________Date: _________

I submit this child for sample collection and testing for paternity evaluation.

Print Child’s Name:

Signature of Guardian Or Child Over 18: _______________________________ Date: __________

ALLEGED FATHER’S PHOTOGRAPH

DO NOT PLACE PHOTO BELOW THIS LINE

I submit myself for sample collection and testing for paternity evaluation.

Print Alleged Father’s Name:

Alleged Father’s Signature: ___________________________Date: _________

I CERTIFY THAT I COLLECTED AND LABELED A SPECIMEN(S) FROM THE PERSON(S) IDENTIFIED HEREIN.

Address where samples are collected:

Child Support Litigation Division

STREET

CITY, TX ZIP CODE

PHONE #

SPECIMEN COLLECTOR FOR MOTHER: SELF

DATE:

SIGNATURE: _______________________________________

SPECIMEN COLLECTOR FOR CHILD: MOTHER

DATE:

SIGNATURE: _______________________________________

SPECIMEN COLLECTOR FOR ALLEGED FATHER: SELF

DATE:

SIGNATURE: _______________________________________

WITNESS: SIGNATURE): _______________________________________

I HEREBY CERTIFY THAT I PACKAGED AND SEALED THE BOX. NO TAMPERING WITH THE SPECIMENTS OCCURRED WHILE THE SPECIMENS WERE IN MY CONTROL. I AFFIRM, UNDER PENALTIES OF PERJURY, THAT THE FOREGOING REPRESENTATION IS TRUE.

NAME OF PERSON PACKAGING SPECIMENS: DATE:

SIGNATURE): _______________________________________

Page 3 of 3 Attachment 5 Paternity Testing Services RFP 3/26/2020

**NOTE: Forms are subject to change**

<Vendor Name>USE ONLY

SPECIMEN CONTAINER SEALED YES / NO SIGNS OF TAMPERING YES / NO

I HEREBY CERTIFY THAT I RECEIVED THE SPECIMENS AT <Vendor Name> AND THERE IS NO EVIDENCE THAT THE PACKAGE HAS BEEN OPENED. I AFFIRM, UNDER

PENALTIES OF PERJURY, THAT THE FOREGOING REPRESENTATION IS TRUE.

SIGNATURE: ___________________________________________________ DATE:____________________________________

CIRCLE ONE: DHL FEDERAL EXPRESS <Vendor Name> CARRIER OTHER