Fill and Sign the 03pa211e Csed 209 R Rescission of Affidavit Acknowledging Paternity is Used to Withdraw Sworn Statement of Paternity Form

*03PA211E-001* OKLAHOMADEPARTMENT OF HUMAN SERVICES Rescission of Acknowledgment of Paternity This is a legal document. Type or print in ink by pressing hard. No cross outs, correction fluid, or alterations allowed. This form is used to withdraw your swor n statement about paternity of a child. This form must be completed and filed with the Oklahoma State Depa rtment of Health (OSDH), Division of Vital Records, within 60 days from the date of the last signature on Form 03PA209E, Acknowledgment of Paternity. When this form is properly completed and filed with the OS DH Division of Vital Records, the man you stated was the natural father on Form 03PA209E, Acknowledgme nt of Paternity, will no longer be the legal father and his name will be removed from the birth certificate. The child's last name will be c hanged to the mother's last name at the ti me of the child's birth. This form must be signed by the rescinding parent (mo ther or father) in the presence of a witness. The witness may not be another parent of the child. The witness may not be related to you. Section l. Child's information as it now appears on birth certificate Child's name First Middle Last Sex, check one Male Female Date of birth (mo/day/yr) Place of birth City County State Section II. Parent's informati on as it appears on the Acknowledgment of Paternity Mother's name First Middle Last Maiden name Father's name First Middle Last Suffix Section III. Presumed father as it a ppears on the Denial of Paternity Was mother married at time of conception or birth? Yes No If yes, husband's name Section IV. Rescinding parent's (m other's or father's) information Parent's name First Middle Last Suffix Date of birth (mo/day/yr) ( ) Daytime phone number Present address City State Zip code Section V. Rescinding parent's signature By signing below, I declare under penalty of perjury that I have read and understand this Rescission of Acknowledgment of Paternit y. I declare the information in this Rescission is true. I understand that by completing this form and filing it with the OSDH Division of Vital Records, I am withdrawing my acknowledgment of paternity fo r the above-named child created by a previously completed Form 03PA209E, Ackn owledgment of Paternity, on or about the date of . Rescinding parent's signature Date and place Signature of witness Printed name of witness Distribution of copies: white to OSDH Division of Vital Reco rds, yellow to OKDHS Child Support Enforcement Division, pink to Mot her, gold to acknowledging Father, green to presumed Father, if any. OKDHS issued 11-1-2006 03PA211E (CSED-209-R) 03PA211E (CSED-209-R) Rescission of Acknowledgment of Paternity Information for completing this Resci ssion of Acknowledgment of Paternity Please read these instructions and the entire form before you sign it. This form must be completed and filed with the Oklahoma State Department of Health (OSDH), Division of Vital Records, withi n 60 days from the date of the last signature on Form 03PA209E, Acknowledgment of Paternity. This form may be completed by either person (m other or father) who originally signed the Acknowledgment of Paternity. The child's last name will be changed to the mother's last name at the time of the child's birth. In add ition, any presumed father who previously deni ed paternity will be added to the birth certificate as the father. Need help in deciding wh o is the biological father? You ma y obtain private genetic testing to determine paternity or receive those services with no up-front cost by opening a case with the Oklahoma Department of Human Services, Child S upport Enforcement Division (CSED). If you have any questions about this form or CSED servic es, please contact CSED at 405-522-2273 in the Oklahoma City calling ar ea, 918-295-3500 in the Tulsa calling area, or toll free at 1-800-522-2922. Instructions for completing this Rescission of Acknowledgment of Paternity After this form has been completed, signed and witnes sed, the rescinding parent gives the pink copy to the mother, the gold copy to the acknowledging father, and the gr een copy to any presumed father. Do not separate the other pages of the Rescission. Mail the white and yellow copies to: Oklahoma State Department of Health Division of Vital Records P. O. Box 53551 Oklahoma City, OK 73152 Disclosure of your Social Security number, and the So cial Security number of your child, is required by federal law. [42 US C §666] CSED will use thes e Social Security numbers only for the purpose of establishing paternity and, if requested or required to do so, establishing and enforcing support for you and your family. 2 OKDHS issued 11-1-2006