Fill and Sign the Name of Defendant or Father Form

NOTICE (TYPE OR PRINT IN BLACK INK) STATE OF NORTH CAROLINA County File No. In The General Court Of JusticeDistrict Court Division AFFIDAVIT OF PARENTAGE Name Of Child(ren) Date Of Birth Child(ren) Social Security No. Birthplace (County And State) VERSUS G.S. 110-132 Name Of Plaintiff (Or Mother) Name Of Defendant (Or Father) Name And Address Of Father Father’s DOB Race Father’s Social Security No. Birthplace Of Father (County And State) Name And Address Of Mother Maiden Name Of Mother Mother’s Social Security No. FATHER’S ACKNOWLEDGMENT Signing this document may impose substantial legal obligations upon you. If you do not fully understand these obligations, you may consult a lawyer, at your own expense, before signing. Providing false or inaccurate information on this document may result in criminal penalties against you. Unless rescinded, this document constitutes an admission of paternity and has the same legal effect as a judgment of paternity for the purpose of establishing your legal duty to support the above-named children. This document may be rescinded by the child(ren)’s mother or the putative father (a) within sixty (60) days of the date this document is executed, or (b) before entry of an order establishing paternity or an order for the payment of child support, whichever is earlier. To rescind this document, you must �le a request for rescission with the Clerk of Superior Court and request a hearing before the district court within the time period indicated above. After sixty (60) days have elapsed, execution of this document may be challenged in court only upon the basis of fraud, duress, mistake, or excusable neglect. I, the undersigned, being duly sworn, freely and voluntarily declare and acknowledge that I am the natural father of the child(ren) named herein, and that the information regarding myself, the natural mother, and the minor child(ren) is true and correct to the best of my knowledge, information and belief. Date My Commission Expires Date Date Signature Of Natural Father Signature Of Person Authorized To Administer Oaths Notary Deputy CSC Assistant CSC Clerk Of Superior Court SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME SEAL (Over) AOC-CV-604, Rev. 4/17 © 2017 Administrative Of�ce of the Courts MOTHER’S AFFIRMATION I, the undersigned, being duly sworn, declare and af�rm that: 1. I am the mother of the above-named child(ren);2. the above-named father is the father of the above-named child(ren); and 3. the above information regarding myself, the father, and the minor child(ren) is true and correct to the best of my knowledge, information, and belief. I also declare and af�rm that I was not married was married when the above-named child(ren) was/were born. NOTE: If you were married to someone other than the above-named father at the time you became pregnant or when the child(ren) was born, you must provide additional evidence (e.g., a court order) that your husband is not the child(ren)’s father. Date My Commission Expires Date Date Signature Of Mother Signature Of Person Authorized To Administer Oaths Notary Deputy CSC Assistant CSC Clerk Of Superior Court SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME SEAL AOC-CV-604, Side Two, Rev. 4/17 © 2017 Administrative Of�ce of the Courts