Acknowledgement Of Paternity
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1NO. _________________________
IN THE DISTRICT COURT
JUDICIAL DISTRICT
{COUNTY, STATE}
ACKNOWLEDGEMENT OF PATERNITY
Child Name:
Birth No.
Birth Place:
DOB:
Address:
City:
State:
Zip:
Mother Name:
SSN:
Marital Status:
DOB:
Address:
City:
State:
Zip:
Putative Father Name:
SSN:
Marital Status:
DOB:
Address:
City:
State:
Zip:
¨ The Mother of the child had multiple sexual partners up to 45 days before the child’s conception
¨ The Mother was married to another man at the time of the child’s conception
¨ A DNA paternity test has been issued
The Putative Father seeks to establish and acknowledge his paternity of the child named above. He
understands and accepts the parental privileges and support obligations intrinsic to paternity
acknowledgement.
Mother Signature
Date
Putative Father Signature
Date
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