Form Vs-27b - Denial Of Parentage (Dop) printable pdf download

Maine Center for Disease Control and Prevention 220 Capitol

Street

11 State House Station

Augusta, Maine 04333-0011

(207) 287-3771

Fax : (207) 287-1093

TTY Users: Dial 711 (Maine Relay)

DENIAL OF PARENTAGE (DOP)

(Please type or print clearly in black ink.)

Check where signed: □ Hospital

□ Division of Support Enforcement and Recovery (DSER)

□ Office of Data, Research, and Vital Statistics (DRVS)

□ Other

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)

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)

Complete and file this form with the Office of Data, Research, and Vital Statistics, with an Acknowledgment of Paternity (AOP) form, to be discharged of all the rights and duties of the

parent for the child listed above. The registration of this form will remove and replace the presumed father listed below with the genetic father listed on a valid AOP

15. Presumed Parent Current Legal Name (First, middle, last, suffix)

16. Presumed 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. Presumed Parent Residence Address (Street and number, city/town, state, zip code)

STATEMENTS OF DENIAL

Presumed Parent’s Initials

Presumed parent must initial each of the statements provided below in order for the DOP to be valid.

I have read and understand the instructions provided and the legal consequences of and the rights and responsibilities that arise from signing the denial.

I understand I have the right to talk with an attorney before signing.

I understand that this denial, in conjunction with a valid Acknowledgment of Paternity (AOP), is the equivalent to an adjudication of the nonparentage

of the presumed parent and discharges the presumed parent from all rights and duties of a parent.

I state that I am not the father or have been adjudicated or acknowledged as the father of the above-named child.

I understand it is a crime to sign this form knowing if another man is an acknowledged or adjudicated father of this child.

I understand that I may rescind this denial by filing a Rescission Form with the Office of Data, Research, and Vital Statistics within 60 days after the

denial has been filed and accepted

I understand that after 60 days of filing the acknowledgment and a denial of parentage, if applicable, with the Office of Data, Research, and Vital

Statistics I must obtain a court determination to rescind or challenge the acknowledgment or denial in order to remove or add a parent.

I swear under penalty of perjury that I have read and understand the statements contained in this Denial of Parentage (DOP). I declare the information is correct to the best of my

knowledge and belief. I am signing this DOP without being subject to force, threats or coercion of any kind.

Signature of Presumed Father

Date Signed (mm/dd/yyyy)

►

STATEMENT OF NOTARY PUBLIC: The individual personally appeared before me and made oath to the truth of the foregoing statements.

State of: _____________________________________________________________

County of: ___________________________________________________________

Signed before me on: ___________________________________________________

Commission Expiration Date: ____________________________________________

Signature of Notary Public

►

VS-27B 06/2016