Fill and Sign the Form 03pa001e Ocss 209 Acknowledgment of Paternity

*03PA209E-001* OKLAHOMA DEPARTMENT OF HUMAN SERVICES Acknowledgment of Pat ernity This legal document establishes paternity under Oklahoma law. Do not sign unless you understand your rights and responsibilities as explained on the back of this form. Type or print in ink by pressing hard. No cross outs, correction fluid, or alterations are allowed. Name of hospital or entity completing form Facility code number Child's information as it now appears on birth certificate . Child's first name MiddleLast SuffixSocial Security Number Date of birth Sex: Male Female Place of birth, c ityCounty State OK Last name of child should now be Mother's first name MiddleLast Maiden name Date of birth Social Security number Daytime phone number Current street a ddress CityStateZip code Was mother married at time of conception or birth? Yes No If yes, husband's name If yes, husband/former husband must complete Form 03PA210E, Denial of Paternity, and attach it to this Form 03PA209E. Father's first name MiddleLast Suffix Date of birth Place of birth, state or foreign country Social Security numberDaytime p hone number Current street address City State Zip code Have you taken a genetic test to determine paternity of this child? YesNo If yes, did the test result show that you are the father of this child?YesNo If the genetic test showed you are NOT the biological father, STOP NOW, DO NOT SIGN. By signing below, I declare under penalty of perjury that I read and understand this Acknowledgment of Paternity. I declare the information in this Acknowledgment is true and: 1. I have been given written and oral notice of my legal rights and responsibilities. 2. I understand this acknowledgment is the equivalent of a judicial adjudication of paternity and that a challenge to the acknowledgment is permitted only under limited circumstances and is barred after two years. 3. By signing this Acknowledgment of Paternity, I give up my right to establish paternity by genetic testing at a later time. Mother signature Date signedFather signature Date signed Witness signature Printed nameWitness signature Printed name Witness a ddress Witness address Parents cannot witness each other's signatures. Witnesses cannot be related to mother or father. Distribution of copies: white to OSDH Division of Vital Records, yellow to OKDHS/Oklahoma Child Support Services , pink to Mother, gold to Father . OKDHS revised 10-1-12 03P A209E (OCSS-209)     03PA209E (OCSS-209) Acknowledgment of Paternity Acknowledgment of Paternity Rights and Responsibilities Please read all information and instructions before signing this Acknowledgment of Paternity. Use this form to establish paternity for a child born to parents who were not married to each other when the child was conceived or born. The biological father of the child named on the acknowledgment will have his name added to the child's birth certificate an d the child's last name can be changed. By signing this Acknowledgment of Paternity to establish lega l fatherhood, you give up your right to establish paternity later by genetic testing. The signers of th is acknowledgment undertake the legal responsibility to support the child. If the child lives with someone other than both parents, the parents may have to pay child support. To safeguard everyone's legal rights in this process, please consi der all of the information below. The only man who should sign this acknowledgment is the bi ological father of this child. Do not sign this acknowledgment if you are not sure you are the biologic al father. You may sign the form later, as there is no time limit on establishing paternity if there is no fa ther listed on the birth certificate. If you sign the form after the child's 18th birthday, the child must sign Form 03PA212E, Adult Child's (18 Years or Older) Consent Form. The adult child states on the form that he or she agrees to the addition of the father's name to his or her birth certificate. Need help in deciding who is the biological father? You may 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, Oklahoma Child Support Services (OCSS). If you have any questions about this form or OCSS services, please contact OCSS at 405-522-2273 in the Oklahoma City calling area, 918-295-3500 in the Tulsa calling area, or toll free at 1-800-522-2922. By signing this Acknowledgment of Paternity you ve rify receiving oral notice of your rights and responsibilities. Please call your local number above to listen to the presentation and follow these steps: At the first voice prompt, select ei ther 1 for English or 2 for Spanish. At the second voice prompt, select 2 for "All other callers." At the third voice prompt, select 4 for "Information on establishing paternity." At the fourth voice prompt, select 2 to "Hear the Notice of Rights and Responsibilities of Paternity." When the mother was married to someone other than the man signing this form at the time of conception or birth another step is required. Her husband must fi ll out and sign Form 03PA210E, Denial of Paternity. If that husband does not dispute paternity for the child named on this form within two years of the birth, he is legally presumed to be the father. This acknowledgment cannot establish paternity for a child more than two years old until a court rules that the husband is not the legal father. If either parent later withdraws this Acknowledgment of Paternity within 60 days, the child's last name will be changed to the mother's last name at the time of the child's birth. A minor parent acknowledging paternity has a 60-day rescission period from the date the minor parent turns age 18. All parents will be notified that paterni ty was withdrawn. Instructions for completing this Acknowledgment of Paternity Complete every blank, including Social Security num bers, if available, and keep all pages together until both parents sign. Sign in the presence of witnesses not related to you. Do not witness each other's signature. Give the pink copy to the mother and the gold copy to the father. Do not separate the other pages of the Acknowledgment. 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 Social Security number of your child, is required by federal law. [42 USC §666] OCSS will use these Social Security numbers only for the purpose of establishing paternity and, if requested or requir ed to do so, establishing and enforcing support for you and your family. 2 OKDHS revised 10-1-12