Paternity Acknowledgement Affidavit printable pdf download

Paternity Acknowledgement Affidavit

NO. _________________________

MOTHER:

IN THE DISTRICT COURT

JUDICIAL DISTRICT

FATHER:

{COUNTY, STATE}

PATERNITY ACKNOWLEDGEMENT AFFIDAVIT

Mother’s Full Name:

Mailing Address:

Phone Number:

Occupation:

SSN:

Marriage Status:

DOB:

Birthplace:

American Citizen:

q Yes q No

Active Duty Member:

q Yes q No

Father Full Name:

Mailing Address:

Phone Number:

Occupation:

SSN:

Marriage Status:

DOB:

Birthplace:

American Citizen:

q Yes q No

Active Duty Member:

q Yes q No

Child Name:

DOB:

Hospital:

Address:

I, the mother listed above, verify that I am the mother of the aforementioned child and consent to having

my name, date of birth, and birthplace listed on the child’s birth certificate. I verify that the father listed

above is the biological father of the child. I request that the child’s name be recorded as follows:

First

Middle

Last

I, the father listed above, verify that I am the father of the aforementioned child and consent to having

my name, date of birth, and birthplace listed on the child’s birth certificate. I verify that I have received

written and oral notice of my rights and responsibilities. I request that the child’s name be recorded as

follows:

First

Middle

Last

Mother’s Signature

Date

Paternity Acknowledgement Affidavit

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