Notice served under section 3107.067 of the Revised Code shall be provided to the putative father of the child in substantially the following form: "_________________________ (putative father's name), who has been named as the father of the unborn child of _________________________ (birth mother's name), or who claims to be the father of the unborn child, is notified that _________________________ (birth mother's name) has expressed an intention to place the child for adoption. On receipt of this notice, _________________________ (putative father's name) may file an action under section 3111.04 of the Revised Code. Under Ohio law, a putative father means a man, including one under age eighteen, who may be a child's father and to whom all of the following apply:

1. (1) He is not married to the child's mother at the time of the child's conception or birth.
2. (2) He has not adopted the child.
3. (3) He has not been determined, prior to the date a petition to adopt the child is filed, to have a parent and child relationship with the child by a court proceeding pursuant to sections 3111.01 to 3111.18 of the Revised Code, a court proceeding in another state, an administrative agency proceeding pursuant to sections 3111.38 to 3111.54 of the Revised Code, or an administrative agency proceeding in another state.
4. (4) He has not acknowledged paternity of the child pursuant to sections 3111.20 to 3111.35 of the Revised Code. For purposes of this notice, _________________________ (putative father's name) is a putative father under the laws in Ohio regarding adoption."