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1.I a m th e[]natu ral m ot her of the chi ld na m ed b e lo w :[]natu ral fa the r[]othe r; ex plai n in Sec tion IVA FFID AVIT IN SUP PO RT OF E S TA BL IS HI NG PA TE RNIT YPetitio ner: Na me (firs t, m idd le, la st) IV -D Case : [ ] TA N FSo cia l S ecu rity Nu mbe r [ ] IV -E Foste r C are[] Me dic aid Only[] Form er A ss is ta n ceRes po nd ent: Na me (fir st, mi ddle , la st)So cia l S ecu rity Nu mbe rNon -IV-D Case:[[] Neve r A ssis ta n ce] Fil e Sta m p Resp ondin g IV -D Case Id en tif ie rResp ondin g Trib un al N um be rIn itia tin g IV -D Case I d en tif ie rIn itia tin g Trib unal N umb erSECTION 1 A Separa te Aff ida vit Is Re quir ed for Eac h C hi ld N ee din g Pater nit y Esta blis he d.I, , o n oa th , u n de r p en alty of p e rju ry depose an d alle g e : Name (fir s t, m id d le , la st)Chi ld ’s Full L e ga l Na me (fir st, mi ddle la st)Chi ld ’s Da te of B irth( M onth , D ay, Y ear)Pl ace o f B ir th (C ity, C ou nty , S ta te )W he re M oth er Got Pregnan t (C it y , C oun ty , S ta te )Dat e M oth er Got Pregn ant(M onth , Y ear)Fu ll T erm Preg na ncy[ ] Y es[ ] No ( If No, exp la in)M oth er’s M aid e n Na me (fir st, mi ddle, last)2 . The ch ild was co n ce iv e d as a re su lt o f se xu a l in te rc ou rs e b etw ee nan d m e du rin g t h e t im e sta ted above .Name (fir st, mi ddle , la st)3 . a. A man is na m ed as th e fa th er on th e ch ild ’s birth c e rti fic a te . [ ] Y es (A tt a ch ed ce rtif ied co py) [ ] NoIf Yes, th e m an ’s n am e an d a dd re ss are :b . A man was m arri ed to th e n a tu ra l m oth er, a nd th e ch ild ’s birt hoccu rre d with in a ye a r of th e en d of th e m arri age.[ ] Y es [ ] NoIf Yes, th e m an ’s n am e an d a dd re ss are : Date marri age end e d(M on th , Da y, Y ea r)c. A man sig n ed a n ack n o w le dgm en t o f pa te rn ity be fore an ac kn ow le dg ment b eca m e a le ga l fin ding o f p ate rn ity und erSta te la w .[ ] Y es (A tt a ch ed ce rtif ied co p y) [ ] Nod . A man acte d as an d pre se n te d him se lf to be th e ch ild ’s fa th e r. [ ] Y es [ ] NoIf Yes, th e m an ’s n am e an d a dd re ss are :e . Genetic te sts were co m ple te d to de te rm in e th e b io lo g ic a l fa th er of th e ch ild . If Yes, a ttach r e su lts .[ ] Y es [ ] NoAff ida vit in Support of E sta blis h in g Pate rn it y OMB 097 0 – 008 5 E xp ir ation D ate : 05 /3 1/2 01 4 Page 1 o f 3 Aff ida vit in Support of E sta blis h in g Pate rn it yP age 2 of 3A FFID AVIT IN SUP PO RT OF E S TA BL IS HI NG PATE RNIT Y, P A G E 2 Initi a tin g IV -D Ca se Iden tifi e rS E CT ION II (T O BE CO MPLE TE D BY MOTHE R ONL Y)1. I h a d se xu a l in te rc ou rs e with an o th er m an (o ther th a n th e m an I am n am in g a s th e ch ild ’s na tu ra l fa th er)d u rin g t h e tim e 3 0 da ys be fo re o r 30 da ys aft e r th e ch il d w as co nce iv e d . [ ] Y es [ ] No(If Yes, co m ple te t h e fo ll o w in g). a. The nam e(s ) a n d ad d re ss(e s) o f th e oth er m an /m en :b. The oth er m an /m en a re bio lo gic a lly re la te d to th e m an I am na m in g as th e ch ild ’s na tu ra l fa th e r.[ ] Y es [ ] No. If Yes, e xp la in th e bio lo g ic a l re la tio n sh ip (e .g., bro th er, c o u sin , u ncle , e tc .)c. I d o n o t be lie ve th e oth er m an /m en is /a re th e fa th e r b e ca u se :2 . I w as m arr ie d at th e tim e of th is ch ild ’s birth [ ] Y es [ ] No (If Yes, co m ple te th e fo llo w in g)a. Husba nd ’s n am e (firs t, m id dle , la st) an d la st kn o w n a ddre ss :b . Exp la in why th e husb an d is not th e fa th er of th is ch ild a n d atta ch all a ppro p riate d o cu m ents , in clu din g div o rc e decre e , g enetic te st re su lt s an d prio r fin din gs of n o n -p a te rn ity , if a n y:3 . is th e fa th e r of th is ch il d . The fo llo w in g fa cts su p po rt m y alle g a tio ns of p a te rn ity : Name (firs t, m id d le , la st)a . We liv e d to ge th er. [ ] Yes [ ] No Dates: To b. I h a ve to ld welfa re o ffic ia ls th a t h e is th e fa th er Loca tio nof th is ch il d . [ ] Yes [ ] Noc. I to ld him th a t h e w as th e fa th er o f th e ch ild . [ ] Yes [ ] Nod . He is na m ed as th e fa th er on th e bir th ce rti fic a te . [ ] Yes [ ] No [ ] Certif ie d C opy Atta ch e de .He sig n e d an ackn o w le dgm ent o f p ate rn ity be fore a n ac kn ow le dg m ent b eca m e a le ga l fin ding o f p ate rn ityun der St ate l a w . [ ] Yes [ ] No [ ] Certif ie d Copy Atta ch e df. He ad m itt ed b ein g th e fa th er of th e ch il d . [ ] Yes [ ] Nog . He se nt ca rd s/le tte rs re gard in g th e pre gn a ncy and/o r abo u tth e c h ild . [ ] Yes[ ] No[ ] Copie s Atta ch e dh . He was pre se n t a t th e birt h of th e ch ild . [ ] Yes [ ] No i. He vis ite d th e ch ild a t th e h o sp ita l fo llo w in g bir th [ ] Yes [ ] No j. He offe re d to pa y abo rti on exp ense s. [ ] Yes [ ] No k. He offe re d to pa y m ed ic a l e xp ense s. [ ] Yes [ ] No l. He paid f o r b irth rela te d exp ense s. [ ] Yes [ ] Nom . He cla im ed th e ch ild o n t a x re tu rn s. [ ] Yes[ ] No [ ]Don’ t Known. He ha s pro vid e d fo o d , clo th in g , g ift s or fin an cia lsu p po rt for th e c h ild . [ ] Yes [ ] No If Y es, exp lain in Section IV o. He liv e d with th e ch ild . [ ] Yes [ ] No If Y es, e xp lain in Section IV p. He v is ite d th e c h ild . [ ] Yes [ ] No If Y es, e xp lain in Section IV q. The c h ild re se m ble s him . [ ] Ph oto attache d [ ] Yes [ ] NoIf Y es, e xp lain in Section IV r.T he re are witn ess e s to m y re la tio nsh ip with him . [ ] Yes [ ] No(If Yes, lis t na m es an d a d d re ss e s an d b riefly describ e re le va n t fa cts kn o w n by each un der Se ctio n IV) Aff ida vit in Support of E sta blis h in g Pate rn it yP age 3 of 3A FFID AVIT IN SUP PO RT OF E S TA BL IS HI NG PA TE RNIT Y, P A G E 3 Initi a tin g IV -D Case Id en tif ie rS E CT ION III (T O BE COMPLE TE D BY FA TH ER ONLY )The fo llo w in g fa cts su p po rt my belie f an d s ta tem en ts th a t I am th e f a th er of th is ch ild :a . The moth er an d I liv e d to geth e r. [ ] Yes [ ] No Dates: T o Loca tio n b. The moth e r t o ld m e th a t I a m t h e fa th er of th e c h ild . [ ] Yes [ ] Noc . I a m n a m ed as th e fa th er on th e bir th ce rti fic a te .[ ] Yes [ ] No[ ] Certif ie d C opy Atta ch e dd . I sig n e d a n a ckn o w le dgm en t of p a te rn ity be fore an ac kn ow le dg m ent b eca m e a le ga l fin ding of p ate rn ity unde r Sta te l a w .[ ] Yes [ ] No[ ] C ertif ie d Copy Atta ch e de . I w as pre se n t at th e birt h of th e ch ild . [ ] Yes [ ] No f.I vis ite d t h e ch ild at th e ho sp it a l fo llo w in g b irth [ ] Yes [ ] No g. I o ffe re d to p a y abo rti on exp e nse s. [ ] Yes [ ] No h. I o ffe re d to pa y m ed ic a l e xp ense s. [ ] Yes [ ] No i. I p a id fo r b irth re la te d exp en se s. [ ] Yes [ ] No j. I cla im ed th e c h ild on ta x re turn s. [ ] Yes [ ] No k.I h a ve p ro vid e d fo o d , clo th in g, g ift s or fin ancia lsu p po rt for th e c h ild . [ ] Yes [ ] No If Y es, e xp lain in Section IVl. I liv e d w ith t h e ch ild . [ ] Yes [ ] No If Y es, e xp lain in Section IV m. I vis ite d t h e ch ild . [ ] Yes [ ] No If Y es, exp lain in Section IV n. The ch ild re se m ble s m e. [ ] Ph oto attache d [ ] Yes [ ] NoIf Y es, e xp lain in Section IV o. The re are witn ess e s to m y re la tio nsh ip with th ech ild ’s m oth er [ ] Yes [ ] No(If Yes, lis t na m es an d a d d re ss e s an d brie fly descri b e re le va n t fa cts kn o w n by each un der Se ctio n IV)S E CT ION IV – OTHE R PE RT INE NT INFO RM ATIO N (in clu din g d et aile d exp la na tion s for “Y es” res po ns esin S ec tion II or Sec tio n III above)[ ] C ontinu ed On Att a ch ed Sheet( s ), inc orp ora te d by re fe re n ce .A ll of the inf or mation and fa cts con tained in th is AFFID AV IT IN SU PPO RT O F ES TA B LIS HING P ATE RNI TY are true an d cor rec t to my be st kno wle dg e an d bel ief . I a gree to su bm it m ys e lf an d, if I a m the cu stod ia n, my ch il dto ge netic te sting as m ay be ne ce ssa ry to esta b lis h pa terni ty .D ate Sig na tu reS w orn to an d Sig ne d be fo re me this Date , C ounty an d Sta teN ota ry Public /O ffic ia l a n d T itleC omm issio n Exp ir es In str u ction s fo r A ff id avit in Support of E sta blis h ing P ate rn it yP age 1 of 3INSTRUC TIONS FOR AFFID AVIT IN SUP PORT OF ESTAB LIS HING PA TERNIT YPUR PO SE O F THE F O RM :This affidavit supplements t h e Uniform Support Petition to summarize evidence to establish p a te rn ity. A separate Affidavit in Su pp o rt o f E sta b li s h in g Pate rn ity is re qu ire d fo r ea ch ch ild needin g pa te rn ity esta blis h m en t. This is ne ce ss a ry s in ce th e circ um sta nce s su rro un din g c o n ce ptio n a n d bir th will d iff e r u nle ss th e ch ild re n a re tw in s. Re min de r: A pu ta tiv e fa th e r m ay pe titio n fo r pate rn ity esta b li s h m en t u n de r UIF SA. All a p p ro pri a te in fo rm atio n fo r th e Affid avit in Sup po rt o f Es tablis h in g Pate rn ity m ust b e c o m ple te d or fu rn is h ed b y th e p a re n t, pro pe rly sig n e d by th e pa re nt, and n o ta rize d as re q uire d. A separa te Affi d avit is re quire d fo r each alle g a tio n of p a te rn ity . Ita lic iz ed text that app ears within a “box ” ref ers to po lic y or pro vid es ad dit ion al inf orm ati on .HE ADING /C APTIO N: [T o be c omp leted by th e Chil d Suppor t (IV -D) Wor ker]• Identify t h e p etit ion er and res pondent n a m e (fir s t, m id dle , la st) an d Socia l Se cu rity Nu mbe r in th e ap p ro pria te sp ace s.• Ch eck th e appro p ria te s p ace to id en tify th e ty p e of ca se : T ANF; IV-E Foste r Ca re , M edic a id only ; fo rm er ass is ta nce , ne ve r ass is ta nce , o r No n-IV-D.TANF means th e ob li g ee ’s fa m ily re ce iv e s IV -A ca sh p aym en ts . A Medic a id only ca se is a ca se wh ere t h eo blig ee’s fa m ily re ce iv e s M ed ic a id bu t d o es no t re ce iv e TAN F (IV -A ca sh paym en ts ).• In the app ro p ria te s p a ce s, if ap plic a ble a n d if kn o w n, en te r th e Re sp o nd in g ju risd ic tio n ’s IV -D ca se id entifi e r, an d Trib un a l num be r.Und er “I V-D ca se id e n tifi e r”, en te r th e nu m be r/i d e n tifi e r id entic a l to th e on e su b m itt e d on th e F edera l Ca se Regis tr y, wh ic h is a le ft -ju stifi e d 1 5 -c h a ra cte r alp h a nu m eric fie ld , a llo w in g all c h a ra cte rs e xce p t aste ris k an d back sla sh , a nd wi th a ll ch a ra cte rs in upp e rc ase . Un der “tr ib u n a l n u m be r”, yo u may ente r t h e docke t n u m be r, cause n u m be r, or a ny oth er a pp ro pria te refere nce nu m be r th a t th e re sp ondin g St ate m ay use to id en tify th e ca se , if kn o wn. The Re sp o nd in g ju ris d ic tio n is th e ju ris d ic tio n th at is work ing t h e cas e at the re qu est of the init ia tin g juris dic tio n.• In th e a ppro p ria te s p ace s, e nte r t h e In it ia tin g ju ris d ic tio n ’s IV -D ca se id e n tifi e r, a n d tr ib u n al n um be r.Und er “I V-D ca se id e n tifi e r”, en te r th e nu m be r/i d e n tifi e r id entic a l to th e on e su b m itt e d on th e F edera l Ca se Regis tr y, wh ic h is a le ft -ju stifi e d 1 5 -c h a ra cte r alp h a nu m eric fie ld , a llo w in g all c h a ra cte rs exce p t aste risk an d back sla sh , a nd wi th a ll ch a ra cte rs in u pp e rc a se . Und er “t ribu n a l n u m be r”, yo u may ente r th e docke t n u m be r, cause n u m be r, or a ny oth er a pp ro pria te refere nce nu m be r w hic h th e in iti a tin g tri bu nal o r age n cy has assig ne d to th e ca se . Th e in it ia tin g ju risd ic tio n is th e ju ris d ic tio n th a t re fe rre d th e c a se to th e re sp o nd in g ju risd ic tio n fo r se rv ic e s.S E CT ION I: (In form atio n to b e co m ple te d or fu rn is h ed by pa re n t o f th e ch ild )En ter th e fu ll n a m e (F ir s t, Mid dle , L ast) of th e p a re n t o r o th er in div id ual c o m ple tin g th e a ffi d a vit .Item 1: Che ck whe the r yo u (the parent) are th e na tura l m oth er or natura l fat her of the ch ild or, if othe r, e xp la in y o ur relat ion sh ip in Section IV.• E nt er the “ C hi ld ’s Ful l L eg al Na me”, “Ch il d’ s Date of Bir th”, and “P lac e of B ir th”.• “ Date Moth er Got P re gn ant” - E nte r the perio d of tim e wh en y o u b elie ve the mother bec am e pre gn a nt (e. g., 4/8 9 or fro m 4/89 to 5/ 89 ). B e sure to inc lu d e both the m onth (or mon ths) and t h e ye ar w hen pro vidi ng date( s). B e a s sp ecif ic as po ss ib le.• “ Fu ll T erm P re gna ncy” - C hec k “Y es ” or “No” to ind ic at e whe the r or not the preg nan cy la sted n in e m on ths. If no , exp la in (e .g., 6 m onth s--c hi ld born prem ature). “W he re M oth er Got P re g na nt” - Li st the Cit y , C ou nty, a nd Stat e. “Mo the r’s Ma id e n Na me” - E nte r the moth er’s maide n nam e, if k no wn. Item 2: En ter th e na m e o f th e ch ild ’s oth er p a re nt in th e bla nk. T his is th e pe rs on with w ho m yo u (the pa re n t co m ple tin g the a ffid avit) ha d se xu a l in te rc o u rs e w hic h re su lte d in th e ch il d ’s co n ce p tio n .Ite m 3: The in fo rm atio n in ite m 3 is in te nd e d to id entify whe th er th e re is a pre su m ed or le g a l fa th e r u n der S ta te la w . Sta te la w s diff e r on whe th er an d h ow a pre su m ptio n of p a te rn ity is cre a te d .Ite m 3a : Che ck “Y es” or “N o” to in dic a te whe th er or n ot a m an is nam ed as th e ch il d ’s fa th er on th e ch ild ’s bir th ce rt if ic a te .If “Y es”, a ttach a ce rti fie d co p y of th e bir th ce rti fic a te an d pro vid e th e m an ’s nam e an d a d d re ss.Th e m an may be th e sa m e man wh o is na m ed as th e fa th e r of th e ch ild in th is affid avit, or he may be a diff e re n t m an . NO TE: So me r e sp on d in g St ate s m ay on ly nee d a re gu la r co p y, ra th e r th a n a ce rtifi e d co py ofth is docu m en t.Ite m 3b: Che ck “Y es” or “N o” to in d ic a te whe th er or n o t a m an was marr ie d to the ch il d ’s na tu ra l m oth e r a n d th e c h ild ’s birth occu rre d with in a ye a r of th e e n d of th e marr ia ge. In clu d e the d ate the marr ia g e end ed. If “Y es”, pro vid e the man ’s na m e a n d addre ss .Th e m an may be th e sa m e man who is na m ed as the fath e r of th e ch ild in this affid a vit, or he may be a diff e re n t m an .Ite m 3c : Che ck “Y es” or “N o” to in dic a te whe th er a m an sig ne d a n ack n o w le dgm ent o f p a te rn ity be fo re a n ackn o w le dg m en t b e ca m e a le g a l fin din g of p ate rn ity under S ta te la w . If “Y es”, attach a ce rti fie d co p y of th e ackn o w le dg m en t.Th e m an may be th e sa m e man wh o is na m ed as th e fa th e r of th e ch ild in th is affid avit, or he may be a diff e re n t m an . NO TE: So me r e sp on d in g St ate s m ay on ly nee d a re gu la r co p y, ra th e r th a n a ce rtifi e d co py ofth is docu m en t.Ite m 3d: Che ck “Y es” or “No ” to in dic a te whe th er o r n ot a m an acte d as an d pre se n te d him se lf to b e th e ch ild ’s fa ther. If“Y es”, p ro vid e th e m an’s na m e an d a d d re ss.Th e m an may be th e sa m e man who is na m ed a s the fath e r o f th e ch ild in this affid a vit, or h e may be a diff e re n t m an .Ite m 3e : Che ck “Y es” or “N o” to in dic a te whe th er or n ot g en etic te sts (e .g ., blo od te sts ) w ere co m ple te d t o de te rm in e th e bio lo g ic a l fa ther o f th e ch il d . If “Y es”, attach th e te st re su lts .SE CT ION II: (T o be co m ple te d by M oth er Onl y)Ite m 1: Che ck “Y es” or “N o” to in dic a te w he th er yo u ( th e m oth e r) did or d id no t h a ve se xu a l in te rc o u rs e (s e x) w ith a noth er man or oth er m en d u ring th e 3 0 da ys be fo re or th e 30 d a ys aft e r th e ch ild was co nce iv e d ( “Dat e M oth er Got Pregn ant”).If yo u had se xu a l in te rc o u rs e with an oth er m an or o th er m en du ring th is pe riod (3 0 da ys befo re or 30 da ys afte r), co m ple te ite ms 1a th ro ug h 1c.Ite m 1a : Pro vid e th e nam e(s ) a n d ad d re ss(e s) of th e o th er m an /m en.Ite m 1b: Che ck “Y es” or “No ” to in dic a te whe th er th e oth er m an /m en are b io lo g ic a lly re la te d t o th e all e ged fa th er. If “Y es”,s ta te th e re la tio nsh ip (e .g ., bro ther, co usin , e tc ). This m ay be re le va n t to ge netic te stin g.Ite m 1c : E xp la in why yo u do no t b elie ve th e oth e r m an /m en is /a re the fa th er of th is ch ild (e .g ., prio r exc lu sio n by genetic testin g ).Ite m 2: Che ck “Y es” or “N o” to in dic a te w he th er or n o t yo u w ere marri ed at th e tim e o f th e ch ild ’s birt h. If “Y es”, co m ple teite ms 2a and 2b .Ite m 2a : Pro vid e th e nam e a nd la st kn o w n a ddre ss of th e man who w as yo u r h u sb a nd at th e tim e o f th e ch ild ’s bir th .Ite m 2b: Exp la in why th e hu sb a n d is no t th e f a th e r. Atta ch app ro pria te do cu m en ts .In str u ction s fo r A ff ida vit in Support of E sta blis h ing P ate rn it y Page 2 of 3 Item 3: Be su re to en te r th e na m e o f th e f a th e r of th is ch il d . Che ck th e appro p ria te a n sw er fo r each sta te m en t (a – r) to su pport th e a ll e ga tio n s of p a te rn ity ag ain st th e all e ged fa th er. Re mem be r to atta ch a n y nece ssa ry , re le va nt do cu m enta tio n . T his in clu d es a ce rtifi e d co p y of th e birth ce rti fica te or t h e ack n o w le dgm en t o f p a te rn ity with th e alle ge d fath er’s na m e on it; an d o th er docu m ents if a va il a ble (e .g ., le tt e rs or c a rd s fro m th e a ll e ged fa th er re gard in g th e pre gnan cy or th e ch il d ).NO TE: so m e resp ond in g State s may only ne ed a re gula r co p y, ra th er th an a ce rti fie d co py, of th ese do cu m ents .SE CT ION III: (T o be co m ple te d by Fa th e r Onl y)Rem in d e r: A pu ta tiv e fa th e r m ay pe titio n fo r pate rn ity esta b lis h m en t un der UIF SA.Che ck th e appro p ria te a n sw er fo r each sta te m en t (a - o ). Re mem ber to att ach an y ne ce ss a ry , re le va n t do cu m en ta tio n.T his in clu de s a c e rt if ie d c o p y of th e bir th ce rti fic a te or ack n ow le dgm ent o f pa te rn ity with yo u r nam e as th e ch ild ’s fa th er o n it; a nd o th e r do cu m ents if a va ila ble ( e .g ., le tte rs or ca rd s fro m th e m oth er re ga rd in g th e pre gn ancy or th e ch il d ).NO TE: so m e re sp ond in g Sta tes m ay o n ly n e ed a re gula r c o py o f a b irt h c e rt ifi c a te o r p a te rn it y ac kn o wle dg m en t, ra th er th an a c e rt ifi e d co py.S E CT ION IV: Pro vid e an y addit io na l in fo rm atio n no t alr e a d y co ve re d whic h mig ht b e he lp fu l in esta bli s h in g pa te rn ity . Onee xa m ple would be th e alle g ed fa th er’s att e nd a nce in a ch ild bir th cla ss with th e moth er.If you are th e mot her, pro vide deta ils to “Y es ” ans wers to item 3, stat em ents n thr ough r in Sec tio n II.n ) Des cri b e a n y fo od, clo th in g, g ift s, o r fin a n cia l s u p port th e alle g e d fa th er h a s pro vid e d fo r t h e c h il d .o) Desc rib e whe re an d whe n t h e alle g e d fa th er liv e d with th e ch ild .p) Pro vid e date s an d c ir c u m sta nce s of an y vis it s be tw ee n th e alle ge d fa th er a n d th e ch il d .q) Desc rib e an y ph ys ic a l re se m bla nce be tw ee n th e alle g e d fa th er an d th e c h il d . At tach p h o to gra phs, if a va ila b le .r) Provid e nam es and add re sse s of a n y witn ess e s to yo u r re la tio nsh ip with th e fa th e r. C on sid e r fri en d s an d re la tive sw ho were aw are of th e p a rt ie s’ d a tin g , on g oin g re la tio nsh ip , or co ha bit a tio n du rin g th e pe riod of co nce p tio n.If you are th e fat her , p ro vide deta ils to “Y es ” answers to sta te m en ts k t h rough o in Section III.k ) Desc rib e an y fo od, clo th in g, g ift s, o r f in a n cia l s u p port yo u p ro vid ed fo r th e ch ild .l) Desc rib e whe re an d whe n y o u liv e d with th e ch ild .m ) Pro vid e date s an d cir c u m sta nce s of an y vis it s be tw ee n yo u an d the ch ild .n) Desc rib e an y ph ys ic a l re se m bla nce be tw ee n y o u an d th e ch ild . A tta ch photo g ra ph s, if a va ila ble .o) Pro vid e nam es and a dd re sse s of a n y witn ess e s to yo u r re la tio nsh ip w ith th e ch ild ’s m oth er. Con sid er fr ie nd s an d rela tive s who were aw are o f th e pa rt ie s’ d atin g, o ng o in g re la tio nsh ip , o r c o habita tio n du rin g th e pe rio d of co nce p tio n. The affid a vit in su pp o rt of esta blis h in g pate rn ity must b e s ig ne d by th e m oth er or fa th e r se ekin g t o esta blis h pa te rn ity . The sig na tu re requir e s a n o ta ry .T he Pape rw or k Redu ctio n Act of 1995This in fo rm atio n co lle ctio n is co nducte d in acc o rd an ce with 42 U.S. C. 651 et se q. a nd 45 CFR 303.7 of th e c h il d su p po rt en fo rc e m en t p ro gra m . St anda rd f o rm s are de sig ne d to pro vid e unifo rm ity and sta nd a rd iz a tio n fo r in te rsta te case p roc essin g . P ub li c re port in g bu rd e n fo r t h is co lle ctio n of in fo rm atio n is estim ate d to ave ra ge un der half a n ho ur pe r re sp o nse . T he re sp on se s to th is co lle ctio n a re mand a to ry in acc o rd an ce with t h e above sta tu te and reg ula tio n . T his in fo rm atio n is su b je ct to Sta te an d F edera l co n fid e n tia lity requir e m en ts ; h ow eve r, the in fo rm atio n will b e f il e d w ith th e tr ib u na l a nd /o r a ge ncy in th e r e sp on din g St ate an d m ay, d ep endin g on Sta te la w , b e dis c lo se d to o th er pa rti e s. An ag en cy m ay no t co n d uct o r s p o n so r, an d a pe rs o n is no t re quir e d to re sp ond to , a co lle ctio n of in fo rm atio n u n le ss it dis p la ys a cu rr en tly va lid OM B c o n tro l n u m ber.In str u ction s fo r A ff id avit in Support of E sta blis h ing P ate rn it y Page 3 of 3