Form Vs 27-C - Rescission/removal Of Acknowledgment Or Denial Of Paternity - Maine Center For Disease Control And Prevention

ADVERTISEMENT

Maine Center for Disease Control and Prevention (Maine CDC)
220 Capitol Street
11 State House Station
Augusta, Maine 04333-0011
(207) 287-3771
Fax : (207) 287-1093
TTY Users: Dial 711 (Maine Relay)
RESCISSION/REMOVAL OF ACKNOWLEDGMENT OR DENIAL OF PATERNITY
(Please type or print clearly in black ink.)
SECTION 1. Child’s information as it appears on the Acknowledgment of Paternity (AOP) form
1. Child’s Name (First, middle, last, suffix)
2. Date of Birth (mm/dd/yyyy)
3. Sex
4. Place of Birth (City or town)
6. Type of Place of Birth
5. County of Birth
Hospital
Freestanding Birthing Center
Clinic/Doctor’s Office
Home Birth
Other (Specify)___________________________________
7. Facility Name (If not an institution, give street and number)
8. Facility Address (Street and number, city/town, state, zip code)
SECTION 2. Parent’s information as it appears on the Acknowledgment of Paternity (AOP) form
9. Mother/Parent Current Legal Name (First, middle, last, suffix)
10. Mother/Parent Name Prior to First Marriage (First, middle, last, suffix)
13. Social Security Number (xxx-xx-xxxx)
11. Date of Birth (mm/dd/yyyy)
12. Birthplace (State, Territory, or Foreign Country)
14. Mother/Parent Residence Address (Street and number, city/town, state, zip code)
15. Father/Parent Current Legal Name (First, middle, last, suffix)
16. Father/Parent Name Prior to First Marriage (First, middle, last, suffix)
17. Date of Birth (mm/dd/yyyy)
18. Birthplace (State, Territory, or Foreign Country)
19. Social Security Number (xxx-xx-xxxx)
20. Father/Parent Residence Address (Street and number, city/town, state, zip code)
SECTION 3. Presumed father’s information as it appears on the Denial of Parentage (DOP) form (if applicable)
21. Father/Parent Current Legal Name (First, middle, last, suffix)
22. Father/Parent Name Prior to First Marriage (First, middle, last, suffix)
23. Date of Birth (mm/dd/yyyy)
24. Birthplace (State, Territory, or Foreign Country)
25. Social Security Number (xxx-xx-xxxx)
26. Father/Parent Residence Address (Street and number, city/town, state, zip code)
SECTION 4. Rescinding party’s information
STATEMENT OF RESCINDING PARTY: I understand this legal document is used to withdraw the legal father and child relationship created by the
Acknowledgment of Paternity (AOP) form that was filed with the Maine Department of Health and Human Services, Data, Research, and Vital Statistics
th
(DRVS) office. This form must be completed and submitted to DRVS prior to the 60
day after the effective date of the acknowledgment and prior to a
court proceeding to adjudicate parentage related to the child. I understand that all parties who signed (signatories) the AOP, and DOP if applicable,
must be notified of this process.
Signature of Rescinding Party
Date Signed (mm/dd/yyyy)
SECTION 5. Statement of Notary Public: The above individual personally appeared before me and made oath to the truth of the foregoing statements.
State of: ________________________________________________________________________________________________________________________________________
County of: ______________________________________________________________________________________________________________________________________
Signed or attested before me on (mm/dd/yyyy): _________________________________________________________________________________________________________
Commission Expiration Date: _______________________________________________________________________________________________________________________
Signature of Notary Public
Date Signed (mm/dd/yyyy)
Data, Research, and Vital Statistics Use ONLY
The AOP, and DOP if applicable, was filed with DRVS on ___________________________________ and is within the 60 day limitation specified in Title 19-A §1867.
Written notification of the request for rescission/removal has been sent to the following parties who signed (signatories) the AOP, and DOP if applicable:
The mother listed on the AOP, and DOP if applicable, on (mm/dd/yyyy) ________________________________________.
The father listed on the AOP on (mm/dd/yyyy) _____________________________________________________________.
The presumed parent listed on the DOP on (mm/dd/yyyy)____________________________________________________.
S:\VS 27-C 06/2016

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go