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Voluntary Acknowledgment Of Paternity - Maine Center For Disease Control And Prevention

Maine Center for Disease Control and Prevention (Maine CDC)

244 Water Street

11 State House Station

Augusta, Maine 04333-0011

(207) 287-3771

Fax : (207) 287-1093

TTY Users: Dial 711 (Maine Relay)

Voluntary Acknowledgment of Paternity

(As Authorized by Title 22 MRSA §2761, sub §4)

PLEASE PRINT IN INK

We,

and

(Full Name of Father)

(Full Name of Mother)

acknowledge that

Father’s Birth Date:

(Full Name of Father)

(Month, Day, Year)

is the natural father of

, born in

(Full Name of Child as shown on Certificate of Birth)

(City or Town)

(Month, Day, Year)

(Full Name of Mother)

Mother’s Social Security Number:

State of Birth:

Father’s Information:

Father’s Social Security Number: _____________________________ State of Birth: ____________________________

Race: __________________

Ancestry: _________________

Education (years): _________________

For information about the Voluntary Acknowledgment of Paternity form see page two; this must be

read before signing the form.

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Voluntary Acknowledgment Of Paternity - Maine Center For Disease Control And Prevention