Affidavit In Support Of Establishing Parentage
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4AFFIDAVIT IN SUPPORT OF ESTABLISHING
INTERNATIONAL FORM
PARENTAGE
Petitioner:
File Stamp
Respondent:
Other Country
Ref. Number
U.S. Case No.
SECTION 1
I, ________________________________________________________ on oath, under penalty of perjury depose and allege:
Name (First, Middle, Last)
[ ]
natural mother of the child named below:
1. I am the
[ ]
natural father
Child's Full Name
Child's Date of Birth
Place of Birth
(First, Middle, Last)
(City,State,Nation)
(Month, Date, Year)
Date Mother Got Pregnant
Full Term Pregnancy
Where Mother Got Pregnant
(City,,State,Nation)
(Month, Date, Year)
[ ]
Yes
[ ]
No (If No, explain)
The child was conceived as a result of sexual intercourse between
2.
and me during the time stated above.
Name (First, Middle, Last)
A man is named as the father on the child's birth certificate. Please attach a copy in all instances.
3.
[ ]
[ ]
No
Yes, If Yes, the man's name and address are:
4.
A man was married to the natural mother, and the child's birth occurred within a year of the end
[ ]
[ ]
Yes If Yes, the man's name and address are:
of the marriage.
No
[ ]
[ ]
A man signed an acknowledgment of paternity.
No
Yes, If Yes, please attach a copy and provide the
5.
man’s name and address:
[ ]
[ ]
A man acted as and presented himself to be the child’s father.
No
Yes
6.
If Yes, the man's name and address are:
[ ]
[ ]
7.
Genetic tests were completed to determine the father of the child.
No
Yes
If Yes, please attach the results and describe in Section 4 the outcome of the test and list the name(s)
and addresses of the man/men tested.
AFFIDAVIT IN SUPPORT OF ESTABLISHING PATERNITY-INTERNTIONAL (3/2004)
PAGE 1 OF 4
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