Paternity Acknowledgment Form - Montana Department Of Public Health & Human Services

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MONTANA DEPARTMENT OF

PATERNITY

PUBLIC HEALTH & HUMAN SERVICES:

VITAL RECORDS BUREAU

ACKNOWLEDGMENT

PO BOX 4210

HELENA, MT 59604-4210

PLEASE TYPE OR PRINT CLEARLY USING A BALL POINT PEN

CHILD'S NAME (First, Middle, Last)

DATE OF BIRTH

SOCIAL SECURITY NUMBER

CITY OF BIRTH

HOSPITAL

MOTHER'S NAME (First, Middle, Last (MAIDEN SURNAME))

MOTHER'S DATE OF BIRTH

MOTHER'S STATE OF BIRTH (If Not U.S.A. Give Country)

MOTHER'S RACE

MOTHER'S SOCIAL SECURITY NUMBER

FATHER'S NAME (First, Middle, Last)

FATHER'S RACE

FATHER'S DATE OF BIRTH

FATHER'S HISPANIC ORIGIN

Education (Elementary/Secondary)

FATHER'S SOCIAL SECURITY NUMBER

(0-12) College (1-4 or 5+)

FATHER'S STATE OF BIRTH (If Not U.S.A. Give Country)

FATHER'S OCCUPATION

FATHER'S PLACE OF EMPLOYMENT

BOTH PARENTS MUST SIGN BEFORE A NOTARY PUBLIC

We the natural mother and father, declare under penalty of perjury under the laws of the State of Montana that the following statements are true and correct. When

completed and filed with the state registrar this Voluntary Declaration of Paternity establishes a father-child relationship identical to the relationship established when a

child is born to married parents. NOTICE TO BOTH PARENTS: THIS IS A LEGALLY BINDING DOCUMENT. Upon signing this declaration, it becomes your duty under

law to provide support and care for the child as the parent. Do not sign this declaration if you do not understand the legal effect of the document or you have doubts

about the paternity of the child. If you wish to withdraw this Acknowledgement, you must do so within 60 days, or before a support or paternity order for the

child is entered, whichever is earlier.

PLEASE PRINT/SIGN USING A BALL POINT PEN

I certify that I am the natural mother. The above information is true and the man

I certify that the above information is true. I make this affidavit to show that I am

named above is the only possible father. I make this affidavit to name the natural

the natural father on my child's birth certificate. I also understand that by

father on my child's birth certificate. I understand the rights, responsibilities,

acknowledging paternity of this child, I accept an obligation to provide child

alternatives, and consequences of signing this affidavit.

support under the laws of the State of Montana. I understand the rights,

responsibilities, alternatives, and consequences of signing this affidavit.

Mother's Signature ______________________________________