Fill and Sign the Form 03pa212e Okdhs

*03PA213E-001* OKLAHOMA DEPARTMENT OF HUMAN SERVICES Rescission of Denial 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 denying paternity of a child. This form must be completed and filed with th e Oklahoma State Department of Health (OSDH), Division of Vital R ecords, within 60 days from the date of the last signature on Form 03PA209E, Acknowledgment of Paternity, that was attached to your Form 03PA210E, Denial of Paternity. When this form is properly completed and file d with the OSDH Division of Vital Records, the man named as the natural father on Form 03PA209E, Acknowledgment of Paternity, of will no longer be the legal father and his name is removed from the birth certificate. The child's last name will be changed to the mother's last name at the time of the child's birth. Your name will be added to the birt h certificate as the father. This form must be signed by th e rescinding presumed 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 information as it a ppears on the Acknowledgment of Paternity Mother's name First Middle Last Maiden name Father's name First Middle Last Suffix Section III. Rescinding presume d father's information Presumed father's name First Middle Last Suffix Date of birth (mo/day/yr) Daytime phone number Present address City State Zip code Place of birth City County State American Indian? Yes No Enrolled? Yes No What tribe(s)? Section IV. Rescinding presumed father's signature By signing below, I declare under penalty of per jury that I have read and understand this Form 03PA213E, Rescission of Denial of Patern ity. 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 denial of pat ernity for the above-named child created by a previously completed Form 03PA210E, Deni al of Paternity, on or about the date of __________ . Rescinding presumed father's signature Date and place Signature of witness Printed name of witness OKDHS issued 11-1-2006 03PA213E 2 OKDHS issued 11-1-2006 03PA213E Rescission of Denial of Paternity Distribution of copies: white to OSDH Division of Vital Records, yellow to OKDHS Child Support Enforcement Division, pink to Mother, Gold to Acknowledgi ng Father, green to Rescinding Presumed Father. Information for completing this Rescission of Denial of Paternity Please read these instructions and the entire form before you sign it. This form must be completed an d filed with the Oklahoma State Department of Health (OSDH), Division of Vital Records, within 60 days from the date of the last signature on Form 03PA209E, Acknowledgment of Paternity that was attached to your Form 03PA210E, Denial of Paternity. This form may only be completed by a presumed father who originally signed the Denial 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 addition, the presum ed father who previously denied paternity will be added to the birth certif icate as the father. Need help in deciding who is the biologic al father? You may obtain private genetic testing to determine paternity or receive thos e services with no up-front cost by opening a case with the Oklahoma Depa rtment of Human Services, Child Support Enforcement Division (CSED). The child must be less than two years old. If you have any questions about this form or CSED services, please contact CSED 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. Instructions for completing this Rescission of Denial of Paternity After this form has been completed, si gned and witnessed, the rescinding presumed father gives the pink copy to the mother, th e gold copy to the acknowledging father, and keeps the green copy. 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 Secu rity number, and the Social Security number of your child, is required by federal law. [42 USC §666] CSED will use these 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.