Fill and Sign the Voluntary Acknowledgment Form

Voluntary Acknowledgment of Parentage by Mother and Father We, the undersigned __________________________________ ( name of mother) and _______________________________________ (name of father) , acknowledge that we are the biological parents of the following child: Name of Child: ____________________________________________________ (Full name of child as it appears on birth certificate) . Sex of Child: ____________________ Social Security Number of Child (if available): ______________________________ Child's Date of Birth: _____________________________ Place of Birth: ___________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ (Name of hospital at street address, city, county, state, zip code) We voluntarily sign this acknowledgment to establish the child's paternity. We understand that this acknowledgment may be used to amend the child's birth certificate and the names of both parents will be on the child's birth certificate. We further understand that this acknowledgment is a legal document with the same binding effect as a court judgment of paternity. Blood and genetic tests may be used to deny paternity only in accordance with the terms described on the attached exhibit. Full Name of child to appear on the amended birth certificate: _____________________________________________________ (First name, middle name, last name) Mother's Information Name of Mother as it appears on the birth certificate: ____________________________ Residence of Mother: _____________________________________________________ ________________________________________________________________________ (Street address, city, county, state, zip code) Social Security Number: __________________________________ Place of Birth: ______________________________________ (City and State) Date of Birth: ________________________ Check one: [ ] I swear or affirm that when this child was born or within _____ days of the child's birth, I was not married. [ ] I swear or affirm that when this child was born or conceived, I was married to someone other than the father of this child. I understand that this form is not effective unless it is accompanied by an affidavit of non-paternity signed by the man to whom I was married or unless the court has determined that the man to whom I was married is not the child's father. I understand further that signing this form is voluntary and that paternity is established as of the date that both parents sign this form and the acknowledgment is properly filed with the child's birth certificate. I have read and understand the information on this form and its attached exhibits, including the information on the process for rescinding (canceling) this acknowledgment of paternity. I understand the rights and responsibilities that result when both parents sign this form. I swear or affirm under the penalties of perjury that the information above is true to the best of my knowledge and belief. Dated: ______________________________ ____________________________________ ____________________________________ (Printed Name & Signature of Mother) STATE OF __________________________ COUNTY OF ________________________ Personally appeared before me, the undersigned authority in and for the aforesaid jurisdiction, the within named _________________________________________ (Name of Mother) , who, after having been first duly sworn, stated on oath that the matters and facts set forth in the above and foregoing document are true and correct as therein stated. ____________________________________ ____________________________________ (Name & Signature of Mother) SWORN to and subscribed before me, this the _______ day of _______________________________, 20_____. ___________________________________ Notary Public My Commission Expires: ________________________ Father's Information Name of Father as it appears on the birth certificate: ____________________________ Maiden Name of Father's Mother: _________________________________ Residence of Father : _____________________________________________________ _______________________________________________________________________ (Street address, city, county, state, zip code) Social Security Number: ________________________________ Place of Birth: _________________________________________________ (City and State) Date of Birth: _______________________________ I understand that signing this form is voluntary and that paternity is established as of the date that both parents sign this form and the acknowledgment is properly filed with the child's birth certificate. I have read and understand the information on this form and its attached exhibits, including the information on the process for rescinding (canceling) this acknowledgment of paternity. I understand the rights and responsibilities that result when both parents sign this form. I swear or affirm under the penalties of perjury that the information above is true to the best of my knowledge and belief. Dated: ________________________________ __________________________________ ___________________________________ (Printed Name & Signature of Father) STATE OF ______________________________ COUNTY OF ____________________________ Personally appeared before me, the undersigned authority in and for the aforesaid jurisdiction, the within named _________________________________________ (Name of Father) , who, after having been first duly sworn, stated on oath that the matters and facts set forth in the above and foregoing document are true and correct as therein stated. ___________________________________ ____________________________________ (Name & Signature of Father) SWORN to and subscribed before me, this the ______ day of ____________________________, 20_____. ____________________________________ Notary Public My Commission Expires: ________________________