Fill and Sign the Declaration of Father Form

Declaration of Father (DCLR) – Page 1 of 3 WPF PS 01.0155 (6/2006) - Chapter 26.26 RCW Superior Court of Washington County of In re Parentage : Petitioner, and Respondent and Respondent. No. Declaration of Father (Parentage) (DCLR) I. Declaration of Father ___________________________________________ [Name] Declares : 1.1 Within the period from _______________ [Date] to _______________ [Date] I had sexual intercourse with ______________________________ [Name] and I believe I am the father of the child, ______________________________ [Name] born on _______________ [Date]. 1.2 Other: II. Military Service [ ] To the best of my knowledge and belief _________________________________ [N ame] is not a service member or a dependent of a service member. To the best of my knowledge and belief ____________________________________ [Name] [ ] is on active duty in the U.S. armed forces (excluding National Guard and reserves); [ ] is on active duty and is a National Guard member or a Reservist residing in Washington; [ ] is not on active duty in the U.S. armed forces (excluding National Guard and reserves); [ ] is not on active duty and is a National Guard member or a Reservist residing in Washington. Declaration of Father (DCLR) – Page 2 of 3 WPF PS 01.0155 (6/2006) - Chapter 26.26 RCW [ ] other: To the best of my knowle dge and belief ___________________________ [Name] [ ] is a dependent of a resident of Washington who is on active duty and is a National Guard member or a Reservist; [ ] is not a dependent of a resident of Washi ngton who is on active duty and is a National Guard member or a Reservist; [ ] other: III. Statement of Non-Representation I have been informed and understand that the a ttorney for the State of Washington (Attorney General/Prosecutor) does not represent me in this matter. I understand that I have the right to retain my own attorney at any time. IV. Uniform Child Custody Jurisdiction and Enforcement Act Statement During the last five years, the child has lived: [ ] in no place other than the state of Washington and with no person other than the declarant or a named party. [ ] in the following places with the following pers ons (list each place the child lived, including the state of Washington, the dates the child lived th ere and the names of the persons with whom the child lived. The present addresses of those persons must be listed in the required Confidential Information Form.): Claims to custody or visitation. [ ] I do not know of any person other than a named party who has physical custody of, or claims to have custody or visitation rights to the child. [ ] The following persons have physical custody of, or claim to have custody or visitation rights to, the child (list their names and the child concerne d below and list their present addresses in the Confidential Information Form. Do not list the responding party.): Involvement in any other proceeding concerning the child: [ ] I have not been involved in any other proceeding regarding the child. Declaration of Father (DCLR) – Page 3 of 3 WPF PS 01.0155 (6/2006) - Chapter 26.26 RCW [ ] I have been involved in the following proceedi ngs regarding the child (list the court, the case number, and the date of the judgment or order): Other legal proceedings concerning the child. [ ] I do not know of any other legal proceedings concerning the child. [ ] I know of the following legal proceedings which concern the child (list the child concerned, the court, the case number and the kind of proceeding): [ ] Other: I declare under penalty of perjury under the laws of th e state of Washington that the foregoing is true and correct. Signed at __________________________, [City] [State] on [Date]. Signature of Father Print or Type Name