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Affidavit Of Unwed Mother Form

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STATE OF MISSOURI

)

) ss.

COUNTY OF ST. CHARLES

)

IN THE CIRCUIT OF ST. CHARLES COUNTY, MISSOURI

PROBATE DIVISION

IN THE MATTER OF

______________________________________________

#_________________________

Minor

AFFIDAVIT OF UNWED MOTHER

I, ___________________________________, the mother of

___________________, a minor ____________________child born on the ______

day of ___________________, _______, in the County of

____________________, State of Missouri, do state that said child was

conceived and born out of wedlock, and that I am the only person having

legal custody and the right to legal custody and the right to legal

custody of said child.

No man has filed an affidavit affirmatively asserting his paternity

to said child; the child’s birth certificate does not name a father; and,

I do not now desire to name the putative father of said child.

Further, the putative father has not paid or assumed any

responsibility for my medical and hospital expenses relating to the

pregnancy of this child nor have I, said child and the putative father

lived together as a family unit. Further, the putative father has not

received this child in his own home, he has not held h____ out to be his

own; and, he has not supported the child in a continuous ad regular

fashion.

I, ________________________, the mother of _______________________,

affirm that the foregoing affidavit is true to the best of my knowledge

and belief.

________________________________

Mother Signature

________________________________

Guardian Ad Litem of Minor

STATE OF MISSOURI, County of St. Charles, On this ______ day of

________________, _______ before me _______________________, a notary

public/clerk in and for said state, personally appeared

_______________________, know to me to be the person__ who executed the

within document

and acknowledged to me that __h____ executed the same for

the purposes therein stated.

Subscribed and sworn to before me this ____ day of _______________,

_______.

_________________________________

(seal)

Clerk

Notary Public

BY:______________________________

Notary commission expires:

Deputy Clerk

Affidavit Of Unwed Mother Form

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