Fill and Sign the Minnesota Parental Form

State of Minnesota District Court County Judicial District: Court File Number: Case Type Family Court In the Matter of: Petitioner INTENT TO CLAIM vs. PARENTAL RIGHTS Respondent I, , state as follows: 1. I am _______ years of age; and reside at (Street Address) (City) (State) (County) 2. I have been advised _____________________________ is the mother of a ______________ child (Male/Female) named ____________________________ born or expected to be born on _________________. 3. I declare I am the father. 4. I understand the mother wishes to consent to the adoption of this child. I do not consent to the adoption of this child, and I understand I must return this form to the court administrator within 30 days of receiving the adoption registry notice. 5. I further understand I must bring a paternity action under the Parentage Act (Minn. Stat. §§ 257.51 to 257.85) within 30 days of receiving the adoption registry notice, or, if the child is not yet born, within 30 days after the birth of the child, unless I am unable to do so. I understand a paternity action is separate from the mailing of this form. In the paternity action, I must state I am the father of the child for one or more of the reasons stated in Minn. Stat. § 257.55, subd. 1. I intend to retain my legal rights with respect to the child, and request to be notified of any further proceedings with respect to custody or adoption of the child. 6. I enter my appearance in this case. DO NOT SIGN UNTIL YOU ARE BEFORE A NOTARY PUBLIC OR COURT ADMINISTRATOR. OATH I have been sworn and say under oath I have read and understand this form. The facts it contains are true and correct to the best of my knowledge, and I understand that by signing this document I admit paternity. I have signed this document freely and voluntarily. Sworn/affirmed before me this _________ of _____________, _______ Notary Public/Court Deputy ACKNOWLEDGEMENT Pursuant to Minn. Stat. § 549.21, the undersigned acknowledges that costs, disbursements, and ADO104 State ENG Rev 9/99 www.courts.state.mn.us/forms Page 1 of 2Signature: Sign only in presence of notary or court clerk Print Name: Street Address: City/State/Zip: Telephone: (______) reasonable attorney and witness fees may be awarded to the opposing party or parties for actions in bad faith; the assertion of a claim or a defense that is frivolous and that is costly to the other party; the assertion of an unfounded position solely to delay the ordinary course of the proceedings or to harass; or the commission of a fraud upon the Court. Sworn/affirmed before me this _________ of _____________, _______ Notary Public/Court Deputy ADO104 State ENG Rev 9/99 www.courts.state.mn.us/forms Page 2 of 2Signature: Sign only in presence of notary or court clerk Print Name: Street Address: City/State/Zip: Telephone: (______)