Affidavit In Support Of Establishing Paternity
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7AFFIDAVIT IN SUPPORT OF ESTABLISHING PATERNITY
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Petitioner
IV-D Non Public Assistance
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IV-D Non PA Medicaid
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Full Services
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Medical Services Only
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Respondent
IV-D Public Assistance
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IV-E Foster Care (IV-D Case)
File Stamp
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Non IV-D
Responding IV-D Case No. _________________________________
Initiating IV-D Case No. ___________________________________
Responding Docket No. ____________________________________
Initiating Docket No. ______________________________________
A Separate Affidavit is Required for Each Child Needing Paternity Established.
SECTION I
I, ______________________________________________, on oath, under penalty of perjury depose and allege:
Name (First, Middle, Last)
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1. I am the
natural mother of the child named below:
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natural father
Child's Full Name
Child's Date of Birth
Place of Birth
(First, Middle, Last)
(City, County, State)
(Month, Date, Year)
Date Mother Got Pregnant
Full Term Pregnancy
Where Mother Got Pregnant
(City, County, State)
(Month, Date, Year)
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Yes
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No (If No, explain)
2. The child was conceived as a result of sexual intercourse between ________________________________________
and me during the time stated above.
Name (First, Middle, Last)
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3. a. A man is named as the father on the child's birth certificate.
Yes
No
(Attach copy)
If Yes, the man's name and address are:
b.
A man was married to the natural mother, and the child's birth occurred within a year of the end of
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the marriage.
Yes
No
If Yes, the man's name and address are:
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c.
A man signed an acknowledgment of paternity.
Yes
No
(Attach copy)
If Yes, the man's name and address are:
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d.
A man acted as and presented himself to be the child's father.
Yes
No
If Yes, the man's name and address are:
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e.
Genetic tests were completed to determine the father of the child.
Yes
No
If Yes, attach results.
Affidavit in Support of Establishing Paternity
OMB No. 0970 - 0085
Page 1 of 3
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