Affidavit Acknowledging Paternity (Page 4 of 4) in pdf

MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES

BUREAU OF VITAL RECORDS

HUSBAND�S DENIAL OF PATERNITX

P.O. BOX 570

JEFFERSON CITY, MISSOURI 65102

INSTRUCTIONS

THIS IS A LEGAL DOCUMENT. PLEASE READ THIS FORM CAREFULLY BEFORE COMPLETING. TYPE OR PRINT EVERYTHING EXCEPT YOUR

SIGNATURE. USE BLACK INK ONLY.

The Mother�s and Father�s Affidavit Acknowledging Paternity forms and the Husband�s Denial of Paternity form must be submitted together.

Any fax, photo or reproduced copies of this form will not be accepted and will be returned for the original. White-out, erasures, typeovers and writeovers are

not acceptable. The information included on these Affidavits must agree with the information provided for the birth certificate.

If the Affidavits are not completed at the hospital to file with the birth record, send all the completed Affidavits to the address above.

Each parent must sign their Affidavit in the presence of a notary public or two (2) witnesses. The parents of this child or anyone related to the parents cannot

be witnesses on any of these forms.

If the mother was married at the time of either conception or birth, or between conception and birth, the name of the husband/ex-husband shall be entered on

the certificate as the father of the child, unless:

1. Paternity has been determined otherwise by a court of competent jurisdiction; or

2. The mother and her husband/ex-husband completes an Affidavit denying that her husband/ex-husband is the father and the mother and natural father

complete an Affidavit acknowledging that he is the father. The natural father will then be shown on the birth certificate.

CHILD�S INFORMATION AS SHOWN ON BIRTH CERTIFICATE

CHILDʼS NAME (FIRST)

(MIDDLE)

(LAST)

DATE OF BIRTH (MM/DD/YYYY)

PLACE OF BIRTH (CITY, COUNTY, STATE)

HOSPITAL OR OTHER ADDRESS WHERE BIRTH OCCURRED

MOTHER�S INFORMATION

NAME (FIRST)

(MIDDLE)

(LEGAL LAST NAME)

(MAIDEN)

DATE OF BIRTH (MM/DD/YYYY)

CURRENT ADDRESS (STREET, CITY, STATE, ZIP)

DENIAL OF PATERNITX

I have received written and oral notice, and I understand my alternatives, the legal consequences and the rights and responsibilities that arise from

completing and signing this Affidavit denying paternity. I am the husband or ex-husband of the mother listed on this affidavit. I do solemnly declare

and affirm that I am not the biological (natural) father of the child listed on this Affidavit and that the statements are true under the pains and

penalties of perjury.

HUSBANDʼS/EX-HUSBANDʼS SIGNATURE

HUSBANDʼS/EX-HUSBANDʼS PRINTED NAME

MUST BE SIGNED IN PRESENCE OF

�

NOTARY OR TWO WITNESSES

NOTARY PUBLIC EMBOSSER SEAL

STATE OF

COUNTY

USE RUBBER STAMP IN CLEAR AREA BELOW

SUBSCRIBED, DECLARED AND AFFIRMED BEFORE ME THIS

DAY OF

YEAR

NOTARY PUBLIC SIGNATURE

MY COMMISSION

EXPIRES

NOTARY PUBLIC NAME (TYPED OR PRINTED)

1. WITNESS SIGNATURE

WITNESS NAME (TYPED OR PRINTED)

DATE WITNESSED

WITNESS ADDRESS (STREET, CITY, STATE, ZIP CODE)

2. WITNESS SIGNATURE