Voluntary Acknowledgment Of Parentage printable pdf download

Commonwealth of Massachusetts

VOLUNTARY ACKNOWLEDGMENT OF PARENTAGE

This is a legal document. Print or type in permanent black ink.

R-130-02112011

We voluntarily sign this acknowledgment to establish the child’s paternity. We understand that this acknowledgment will be filed with 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.

We acknowledge that we are the biological parents of the following CHILD:

Social Security #

(if assigned):

Full name to appear on the birth certificate:

First, Middle, Last

If amending, name as it now appears:

First, Middle, Last

Birthplace:

City/Town

State

Date of Birth (Month spelled out, Day, Year)

Sex (M/F)

MOTHER

Social Security #

Full name to appear on the birth certificate:

First, Middle, Last

Surname at my Birth or Adoption

Residence:

No. & Street Name

City/Town

State

Zip Code

Date of Birth (Month spelled out, Day, Year)

Birthplace:

City/Town

State (Country if not U.S.)

Check one:

I swear or affirm that when this child was born or within 300 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 will not add the father to the birth certificate unless accompanied by an Affidavit of Non-Paternity or Affidavit of Non-Parentage

signed by that spouse or unless the court has determined that the spouse to whom I was married is not the child’s legal parent.

I understand that signing this form is voluntary and that paternity is established as of the date that this form is completed by both parents and properly

filed at the offices of the city or town clerk where the child was born or the State Registry of Vital Records and Statistics. I have read and understand

the information on this form, and on the Notice of Rights and Responsibilities: Voluntary Acknowledgment of Parentage, 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 hereby swear or affirm under the penalties of perjury that the information above is true to the best of my knowledge and belief.

On this ___________ day of ____________________, _________ before me, the undersigned

notary public, personally appeared ________________________________________________

who proved to me through satisfactory evidence of identification, which was or were

Signature of Mother

___________________________________________________ to be the person whose name is

signed on this document and who swore or

affirmed to me that the contents of the

document are truthful and accurate to the best

Form read in

of her knowledge and belief and that she signed

Notary Public

this form voluntarily for its stated purpose.

FATHER