Looking for a U.s. Department Of Health And Human Services Forms And Templates? Download it for free!

Please print or type.

Father’s Affidavit

I, ________________________________________________________________, hereby swear or affirm that:

First, middle, and last name of father

 I have read the disclosure of basic rights and responsibilities of acknowledging paternity printed on the back of this form, and I have

had and opportunity to obtain legal advice if I so desire.

 I am the father of __________________________________________________________, born on __ __ / __ __ / __ __ __ __, in

First, middle, and last name of child as shown on birth certificate.

Date of birth (mm/dd/yyyy)

______________________________________ to _______________________________________________________.

City & State of birth

Full name of mother as shown on the birth certificate.

 I desire to amend the birth certificate of this child pursuant to KSA 38-1130.

Additional information required:

Father’s state of birth: _______________________________

Father’s date of birth:

__ __ / __ __ / __ __ __ __

Father’s highest education: ___________________________

(mm/dd/yyyy)

Father’s Social Security Number: __ __ __ / __ __ / __ __ __ __

Father’s race: ______________________________________

Father’s address: _____________________________________________________________________________________________

Street

City

State

Zip code

_____________________________________

Signature of Father

Subscribed and sworn to before me at ___________________________ on this __________ day of ______________________, _______.

_____________________________________

Signature of Judge or authorized Hearing Officer

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Mother’s Affidavit

I, ________________________________________________________________, hereby swear or affirm that:

First, middle, and last name of mother

 I have read the disclosure of basic rights and responsibilities of acknowledging paternity printed on the back of this form, and I have

had and opportunity to obtain legal advice if I so desire.

 I am the mother of __________________________________________________________, born on __ __ / __ __ / __ __ __ __, in

First, middle, and last name of child as shown on birth certificate.

Date of birth (mm/dd/yyyy)

______________________________________.

City & State of birth

 ____________________________________________ is the father of this child, and I desire to amend the birth certificate of this child

Full name of Father

pursuant to KSA 38-1130.

Mother’s daytime phone number: (__ __ __) __ __ __ - __ __ __ __

Mother’s date of birth:

__ __ / __ __ / __ __ __ __

Mother’s Social Security Number __ __ __ / __ __ / __ __ __ __

(mm/dd/yyyy)

Mother’s address: ________________________________________________________________________________________________

Street

City

State

Zip code

_____________________________________

Signature of Mother

Subscribed and sworn to before me at ___________________________ on this __________ day of ______________________, _______.

_____________________________________

Signature of Judge or authorized Hearing Officer

Page 2 of 3

Kansas Department of Health and Environment

Paternity Consent Form For Birth Registration Form - Kansas Department Of Health And Environment Page 2

Related Articles

Related forms

Related Categories