Form 1798 - Parent Survey On The Acknowledgment Of Paternity (Aop)
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1
2P
(AOP)
ARENT SURVEY ON THE ACKNOWLEDGMENT OF PATERNITY
Mandated by Law
This Survey should be completed after the AOP has been signed or a person has declined to sign the AOP.
Hospital/Entity Name & Location:_______________________________ Entity Code: _________
Child’s Name: ______________________________________________ Date of Birth: ________
Please read and INITIAL the following:
STATEMENTS
MOTHER
FATHER
1. I was given the opportunity to sign an Acknowledgment of Paternity.
________
________
2. I choose NOT to complete an Acknowledgment of Paternity.
________
________
If you initial #2, please skip questions 3 through 8.
________
________
3. I was made aware that I could have a DNA test done before I signed
the AOP.
4. I was given written and oral information regarding the benefits, rights
________
________
and responsibilities of an AOP, an explanation of those rights and
responsibilities, and information about child support.
5. The biological father who signed this AOP will have all legal rights
________
________
and duties of a parent. This may include the legal responsibility for
financial and medical support of the child named in this AOP.
6. If I change my mind, a Rescission of Acknowledgment (VS-158)
must be filed within the earlier of 60 days of signing the
________
________
Acknowledgment of Paternity or the date a proceeding involving the
child is initiated before a court.
7. After 60 days, I may challenge the AOP in court and must prove
________
________
fraud, duress, or material mistake of fact.
8. I was given a completed copy of the AOP with the benefits, rights,
________
________
and responsibilities on the back.
Mother’s Printed Name: __________________________________________
ID Type: _____________________________
Mother’s Signature: _____________________________________________
Phone Number: ________________________
Father’s Printed Name: __________________________________________
ID Type: _____________________________
Father’s Signature: _____________________________________________
Phone Number: ________________________
Certified Staff Signature: ________________________________________
Date: ________________________________
Presumed Father: After you read the Denial of Paternity and Change of Mind sections of the rights and responsibilities,
please read the statement below and initial.
After I have signed the Denial of Paternity and it has been filed with the Vital Statistics Unit, my legal rights and
responsibilities to this child will be terminated. If I change my mind, a Rescission of Acknowledgment of Paternity (VS-158)
can be filed within the earlier of 60 days of signing the Acknowledgment of Paternity or the date a proceeding involving the
child is initiated before a court. After 60 days, I may challenge the AOP in court and must prove fraud, duress, or material
Initial here
mistake of fact.
_______
Presumed Father’s Printed Name: _________________________________
ID Type: _____________________________
Presumed Father’s Signature: ____________________________________
Phone Number: ________________________
Date: ______________________________
Certified Staff Signature: ________________________________________
September 2011
Form 1798
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