Form Vs27-A - Acknowledgment Of Paternity (Aop) - Maine Center For Disease Control And Prevention
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3Maine 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)
ACKNOWLEDGMENT OF PATERNITY (AOP)
(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, other 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
Unknown
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)
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)
EDUCATION
ANCESTRY
RACE
(Highest grade completed at time of child’s birth)
(Check one box below and must specify if other)
(Check all that apply)
□
□
□
□
th
8
grade or less
Hispanic
White
Other Asian
□ Mexican, Mexican American, Chicana
□ Specify ____________
□
□
th
9-12
grade, no diploma
Black or African American
□ Puerto Rican
_____________________
□
□
High school graduate or GED completed
American Indian or Alaska Native
□ Cuban
□
Native Hawaiian
□ Specify _________________
□
□ Other
Some college credit, but no degree
□
__________________________
Guamanian or Chamorro
□
Non-Hispanic
□
Associate Degree, AA, AS
□
Asian Indian
□
Samoan
□ Italian
□
□
Bachelor’s Degree, BA, AB, BS
Chinese
□
□ African
Other Pacific Islander
□
□
Filipino
Master’s Degree, MA, MS, MEng, MSW, MBA
□ American
□ Specify ____________
_____________________
□ Haitian
□
□
Japanese
Doctorate, PhD, EdD or Professional Degree,
□ Pakistani
□
Other
MD, DDS, DVM, LLB, JD
□
Korean
□ Ukrainian
□ Specify ____________
□
None
□ Nigerian
□
Vietnamese
_____________________
□ Taiwanese
□
Unknown
□
Don’t know/ Not sure
□ Other, Specify___________________
□
Refused
□
Unknown
STATEMENT OF PARENTS: We affirm, under penalty of perjury, by the woman giving birth (mother/parent) and the man (father/parent) seeking to
establish his paternity, that we have examined the statements on page 2 of this form and that it is correct to the best of our knowledge and belief. We are
voluntarily signing this acknowledgment of paternity without being subject to force, threats or coercion of any kind.
Signature of Mother/Parent
Date Signed (mm/dd/yyyy)
Signature of Father/Parent
Date Signed (mm/dd/yyyy)
►
►
STATEMENT OF NOTARY PUBLIC: The above individuals personally appeared before me and made oath to the truth of the foregoing statements.
State of: _____________________________________________________________
State of: _____________________________________________________________
County of: ___________________________________________________________
County of: ___________________________________________________________
Signed or attested before me on (mm/dd/yyyy): ______________________________
Signed or attested before me on (mm/dd/yyyy): ______________________________
Commission Expiration Date: ____________________________________________
Commission Expiration Date: ____________________________________________
Signature of Notary Public
Signature of Notary Public
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S:\VS27-A 06/2016
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