Paternity Acknowledgment Form - Montana Department Of Public Health & Human Services Page 2
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2STATE OF MONTANA
DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES
OFFICE OF VITAL STATISTICS
NOTICE OF WITHDRAWAL OF PATERNITY ACKNOWLEDGMENT
I, _______________________________________, signed an acknowledgment of paternity
(Your name)
for ________________________________ on ____________________________________.
(Child’s name)
(Date paternity acknowledgment was signed)
A copy of this notice of withdrawal was provided to me with the paternity acknowledgment
form. Having reconsidered my action signing the acknowledgment, I hereby withdraw, cancel
and rescind my acknowledgment.
I understand that this withdrawal is useless and of no effect unless it is filed with the Montana
Department of Public Health and Human Services within 60 days of the date the paternity
acknowledgment was signed, or before a support or paternity order for the child is entered,
whichever is earlier. I understand that to file this document, I must present it in person to the
department at the address below, or mail it to the department at the mailing address below so that
it is received and available for filing with the department’s vital records before the withdrawal
period ends.
I further certify that I have provided a copy of this notice to the other party who signed the
acknowledgment of paternity.
______________________________
_________________________________
Date
Signature
State of:___________________________
County of:_________________________
___________________________________personally appeared before me. His identity as the
signer of the above instrument was proved to me, and he acknowledged that he executed it.
Subscribed and sworn to before me this______day of _____________________, 20________
Notary Public Signature:_________________________
(SEAL)
Printed Name of Notary:_________________________
Notary Public for the State of:_________________
Residing at:_______________________________
My Commission Expires:____________________
INSTRUCTIONS FOR FILING THIS WITHDRAWAL NOTICE
You may file this document:
IN PERSON:
BY MAIL:
DPHHS
DPHHS
Office of Vital Statistics
Office of Vital Statistics
111 Sanders St., Rm 209
PO Box 4210
Helena, MT 59620
Helena, MT 59604-4210
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