Fill and Sign the Notice of Withdrawal of Paternity Acknowledgment Form

Rev. 2/05 STATE OF MONTANA DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES OFFICE OF VITAL STATISTICS NOTICE OF WITHDRAWAL OF PATERNITY ACKNOWLEDGMENT I, _____________________________________________, si gned an acknowledgment of paternity for (Your name) ____________________________ Date of birth: _____________on ____________________________ (Child’s name) (Date paternity acknowledgment was signed) A copy of this notice of withdrawal was provided to me with the paternity acknowledgment form. Having reconsidered my action signing the ack nowledgment, I hereby withdraw, cancel and rescind my acknowledgment. I understand that this withdrawal is useless and of no effect unless it is filed with the Montana Department of Public Health and Human Services within 60 days of the date the paternity acknowledgment was signed, or before a support or paternity order for the child is entered, whichever is earlier. I understand that to file th is document, I must present it in person to the department at the address below, or mail it to th e department at the mailing address below so that it is received and available for filing with the department’s vital records before the withdrawal period ends. I further certify that I have provided a copy of this notice to the other party who signed the acknowledgment of paternity. ___________________________________ Signature __________________________________ Date State of: ________________________ County of: ________________________ ___________________________________personally appeared before me . His identity as the signer of the above instrument was proved to me, and he ack nowledged that he executed it. Subscribed and sworn to before me this _______ day of _______________________, 20__________ N ota ry P ublic S ig natu re __ SEAL Printed Name of Notary Notary Public for the State of:___________________ Residing at:__________________________________ My Commission Expires: _______________________ INSTRUCTIONS FOR FILING THIS WITHDRAWAL NOTICE You may file this document: IN PERSON: BY MAIL: DPHHS DPHHS Office of Vital Statistics OR Office of Vital Statistics 111 Sanders St., Rm 209 PO Box 4210 Helena, MT 59620 Helena, MT 59604-4210