Acknowledgment Of Paternity Affidavit - Ohio Department Of Job And Family Services (Page 2 of 2) in pdf

PLEASE READ THE IMPORTANT INFORMATION ON THE REVERSE SIDE BEFORE COMPLETING THIS PAGE

*Please type or print in dark blue or black ink*

CHILD’S INFORMATION

Name: __________________________________________________________________________________________________

(First)

(Middle)

(Last)

(Suffix, if applicable (i.e. Jr/Sr))

Date of Birth: ____________________________

Place of Birth: __________________________________________

(Mo/Day/Year)

(City)

(State)

(County)

Current Residence: _______________________________________________________________________________________

(Full Street Address)

(City)

(State)

(Zip)

f a birth certificate for the child has already been filed, do you now wish to change the child’s name?

YES

If “YES”, give the child’s new name: __________________________________________________________________________

(First)

(Middle)

(Last)

(Suffix, if applicable (i.e. Jr/Sr))

MOTHER’S AFFIRMATION

(Name at the time of child’s birth)

Name: ________________________________________________________________ Maiden Name: ______________________

(First)

(Middle)

(Last)

Address: _________________________________________________________________________________________________

(Full Street Address)

(City)

(State)

(Zip)

Date of Birth: ______________________________

Social Security Number: _________________________________

(Mo/Day/Year)

(If you do not have a SSN enter N/A)

You are required to provide your social security number in accordance with federal law at

42 USC 666, your social security number will be used for child support purposes only.

SIGNATURE AND NOTARIZATION

State of _____________, County of _____________, ss. I state under oath or by affirmation that I have read or had read to me all

information on both sides of this form; that the information I have supplied for this form is true to the best of my knowledge and belief; that

I have received information regarding my legal rights and responsibilities; and that I am the natural mother of the child named on this form

and I assume the parental duty of support of the child.

_______________________________________________________

Signature of the Mother

(Please read page one (1) before signing your name)

(SEAL)

Before me appeared the above named person (mother) who signed this affidavit

under oath or by affirmation on this ________________ day of ________________, in the year ___________.

___________________________________

______________________

Signature of Notary Public

Expiration of Commission

FATHER’S AFFIRMATION

Name: ______________________________________________________________________

(First)

(Middle)

(Last)

(Suffix, if applicable (i.e. Jr/Sr))

Address: _________________________________________________________________________________________________

(Full Street Address)

(City)

(State)

(Zip)

State or: ___________________________________

Country of Birth

Date of Birth: ______________________________

Social Security Number: _________________________________

(Mo/Day/Year)

(If you do not have a SSN enter N/A)

You are required to provide your social security number in accordance with federal law at

42 USC 666, your social security number will be used for child support purposes only.

SIGNATURE AND NOTARIZATION

State of _______________, County of _____________, ss. I state under oath or by affirmation that I have read or had read to me all

information on both sides of this form; that the information I have supplied for this form is true to the best of my knowledge and belief; that

I have received information regarding my legal rights and responsibilities; that I consent to the jurisdiction of the courts of this state; and

that I am the natural father of the child named on this form and I assume the parental duty of support of the child.

___________________________________________________________

Signature of the Father

(Please read page one (1) before signing your name)

(SEAL)

Before me appeared the above named person (father) who signed this affidavit

under oath or by affirmation on this _____________ day of _____________________, in the year ____________.

____________________________________

______________________

Signature of Notary Public

Expiration of Commission

EBC #

CSEA #

Registrar #

CPR #

ODH File #

JFS 07038 (Rev. 5/2014)

Page 2 of 2

Acknowledgment Of Paternity Affidavit - Ohio Department Of Job And Family Services Page 2

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