State Of Nevada Declaration Of Paternity

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State of Nevada
Declaration of Paternity
THIS IS A LEGAL DOCUMENT. TYPE OR PRINT IN BLACK INK. Parents are to be given a copy of this completed
document prior to sending to the Office of Vital Records (see bottom of page).
PLEASE READ PAGE 2 BEFORE COMPLETING.
SECTION A
ALL PARTS OF SECTIONS A & B MUST BE COMPLETED AND SECTION D WITNESSED
NAME OF CHILD – FIRST
MIDDLE
LAST
Child
SEX OF THE CHILD
DATE OF BIRTH (Month, Day, Year
HOSPITAL NAME
CITY
Place of Birth
COUNTY
STATE
NAME OF FATHER – FIRST
MIDDLE
LAST
Father’s
Information
DATE OF BIRTH (Month, Day, Year)
SOCIAL SECURITY NUMBER
STATE OR FOREIGN COUNTRY OF BIRTH
CURRENT ADDRESS (Number, Street, City, State Zip)
NAME OF MOTHER – FIRST
MIDDLE
LAST
Mother’s
DATE OF BIRTH (Month, Day, Year)
SOCIAL SECURITY NUMBER
STATE OR FOREIGN COUNTRY OF BIRTH
Information
CURRENT ADDRESS (Number, Street, City, State Zip)
SECTION B
As part of the filing procedure the child’s name may be changed at this time from the name appearing on the original birth
certificate. A name change requested after this declaration is filed may require a court order. No white-out, erasures or cross-outs will be allowed
in this section.
First
Middle
Last
SECTION C
READ OTHER SIDE BEFORE SIGNING
I declare under the penalty of perjury that:
I declare under the penalty of perjury that:
The information I have provided is true and correct.
The information I have provided is true and correct.
o
o
I am the legal father of the child named on this declaration.
I am the natural mother of the child named on this
o
o
I have read and understand the rights and responsibilities
declaration.
o
described on the back of this form.
The man signing this form is the only possible father of this
o
o
I have been orally/audio informed of my rights and
child.
responsibilities.
I have read and understand the rights and responsibilities
o
I understand that by signing this form I voluntarily consent
described on the back of this form.
o
to the establishment of paternity and accept all of the rights
I have been orally/audio informed of my rights and
o
and responsibilities as the legal father of this child.
responsibilities.
o
I wish to be added to the child’s birth certificate.
o
I understand that by signing this form I am establishing the
A genetic test has not determined that another man is the
man signing this form as the legal father of this child with all
o
legally presumed father of this child.
the rights and responsibilities of a legal father.
There is no court order or other Acknowledgment of
I consent to adding the name of the man signing this form to
o
o
Paternity form naming another man as the legal father of
the birth certificate of the child’s birth certificate
this child.
A genetic test has not determined that another man is the
o
legally presumed father of this child.
There is no court order or other Acknowledgment of
o
Paternity form naming another man as the legal father of
this child.
SIGNATURE OF FATHER
DATE SIGNED
SIGNATURE OF MOTHER
DATE SIGNED
WITNESS OF FATHER’S SIGNATURE
DATE SIGNED
WITNESS OF MOTHER’S SIGNATURE
DATE SIGNED
Once this document is signed by all parties, please provide copies to the mother, father and hospital. The original document
must be sent to the Nevada Office of Vital Records, 4150 Technology Way, Suite 104, Carson City, NV 89706 for filing.

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