PARENT SURVEY ON THE ACKNOWLEDGMENT OF PATERNITY (AOP)
MANDATED BY LAW
This Survey should be completed after the AOP has been signed or a person has declined to
sign the AOP.
Hospital/EntityName & Location:____________________________________Entity Code:_______
Child’s Name: ____________________________________________ Date of Birth: ____________
Please read and INITIAL the following:
1. I was given the opportunity to sign an Acknowledgment of Paternity.
2. I did not complete an Acknowledgment of Paternity.
3. I was made aware that I could have a DNA test done before I signed
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. I was given information that 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. I was given information that I have 60 days from the date the AOP is
filed to change my mind and file a rescission in court.
7. I was given information that after 60 days I may challenge the AOP
in court and must prove fraud, duress, or material mistake of fact.
8. I was given information that after four years from the date the AOP is
filed, I can no longer challenge the AOP. Minors may challenge until
4 years after they become an adult.
9. I was given a completed copy of the AOP with the benefits, rights,
and responsibilities on the back.
Mother’s Printed Name:______________________________________
Father’s Printed Name:_______________________________________
Certified Staff Signature:_____________________________________
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. I have 60 days from the date the AOP is filed to change my mind and
file a rescission in court. After 60 days, I may challenge the AOP in court and must prove fraud, duress, or material
mistake of fact. After four years from the date the AOP is filed, I can no longer challenge the AOP. _____
Presumed Father’s Printed Name: _________________________________ID Type:________________________
Presumed Father’s Signature: ____________________________________Phone Number: __________________