Affidavit in Support of Establishing Paternity

AFFIDAVIT IN SUPPORT OF ESTABLISHING PATERNITY

Petitioner: IV-D Non Public Assistance
IV-D Non PA Medicaid
Full Services
Medical Services Only

Respondent: IV-D Public Assistance
IV-E Foster Care (IV-D Case)
Non IV-D

A Separate Affidavit is Required for Each Child Needing Paternity Established.

SECTION I

I, , on oath, under penalty of perjury depose and allege:

1. I am the natural mother of the child named below: natural father

2. The child was conceived as a result of sexual intercourse between and me during the time stated above.

3. a. A man is named as the father on the child's birth certificate. Yes No

b. A man was married to the natural mother, and the child's birth occurred within a year of the end of the marriage. Yes No

c. A man signed an acknowledgment of paternity. Yes No

d. A man acted as and presented himself to be the child's father. Yes No

e. Genetic tests were completed to determine the father of the child. Yes No

SECTION II (TO BE COMPLETED BY MOTHER ONLY)

1. I had sexual intercourse with another man during the time 30 days before or 30 days after the child was conceived. Yes No

a. The name(s) and address(es) of the other man/men:

b. The other man/men are biologically related to the man I am naming as the child's natural father. Yes No

c. I do not believe the other man/men is/are the father because:

2. I was married at the time of this child's birth. Yes No

a. Husband's name and last known address:

b. Explain why the husband is not the father of this child and attach all appropriate documents:

3. is the father of this child. The following facts support my allegations of paternity:

a. We lived together. Yes No

b. I have told welfare officials that he is the father of this child. Yes No

c. I told him that he was the father of the child. Yes No

d. He is named as the father on the birth certificate. Yes No Certified Copy Attached

e. He admitted being the father of the child. Yes No

f. He signed an acknowledgment of paternity. Yes No Certified Copy Attached

g. He sent cards/letters regarding the pregnancy and/or about the child. Yes No Copies Attached

h. He was present at the birth of the child. Yes No

i. He visited the child at the hospital following birth. Yes No

j. He offered to pay for an abortion/medical expenses. Yes No

k. He paid for birth related expenses. Yes No

l. He claimed the child on tax returns. Yes No Don't Know

m. He has provided food, clothing, gifts or financial support for the child. Yes No

n. He lived with the child. Yes No

o. He visited the child. Yes No

p. The child resembles him. Photo attached Yes No

q. There are witnesses to my relationship with him. Yes No

SECTION III (TO BE COMPLETED BY FATHER ONLY)

The following facts support my belief and statements that I am the father of this child:

a. The mother and I lived together. Yes No

b. The mother told me that I am the father of the child. Yes No

c. I am named as the father on the birth certificate. Yes No Certified Copy Attached

d. I signed an acknowledgment of paternity. Yes No Certified Copy Attached

e. I was present at the birth of the child. Yes No

f. I visited the child at the hospital following birth. Yes No

g. I offered to pay for an abortion/medical expenses. Yes No

h. I paid for birth related expenses. Yes No

i. I claimed the child on tax returns. Yes No

j. I have provided food, clothing, gifts or financial support for the child. Yes No

k. I lived with the child. Yes No

l. I visited the child. Yes No

m. The child resembles me. Photo attached Yes No

n. There are witnesses to my relationship with the child's mother. Yes No

SECTION IV -- OTHER PERTINENT INFORMATION

Include detailed explanations for "Yes" responses in Section II or Section III above.

All of the information and facts contained in this AFFIDAVIT IN SUPPORT OF ESTABLISHING PATERNITY are true and correct to my best knowledge and belief. I agree to submit myself and, if I am the custodian, my child to genetic testing as may be necessary to establish paternity.