Affidavit In Support Of Establishing Paternity Page 2
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7AFFIDAVIT IN SUPPORT OF ESTABLISHING PATERNITY, PAGE 2
Initiating IV-D Case No.
SECTION II (TO BE COMPLETED BY MOTHER ONLY)
1. I had sexual intercourse with another man (other than the man I am naming as the child's natural father)
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during the time 30 days before or 30 days after the child was conceived.
Yes
No.
(If Yes,
.
complete the following)
a.
The name(s) and address(es) of the other man/men:
b.
The other man/men are biologically related to the man I am naming as the child's natural father.
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Yes
No. If Yes, explain the biological relationship
:
(e.g., brother, cousin, uncle, etc.)
c.
I do not believe the other man/men is/are the father because:
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2. I was married at the time of this child's birth.
Yes
No.
.
(If Yes, complete the following)
a.
Husband's name
and last known address:
(first, middle, last)
b.
Explain why the husband is not the father of this child and attach all appropriate documents, including
divorce decree, blood test results and prior findings of nonpaternity, if any:
3. _______________________________ is the father of this child. The following facts support my allegations of paternity:
Name (First, Middle, Last)
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a. We lived together.
Yes
No
Dates:_________To_________
Location_____________________
b. I have told welfare officials that he is the father
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of this child.
Yes
No
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c. I told him that he was the father of the child.
Yes
No
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d. He is named as the father on the birth certificate.
Yes
No
Certified Copy Attached
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e. He admitted being the father of the child.
Yes
No
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f. He signed an acknowledgment of paternity.
Yes
No
Certified Copy Attached
g. He sent cards/letters regarding the pregnancy
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and/or about the child.
Yes
No
Copies Attached
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h. He was present at the birth of the child.
Yes
No
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i.
He visited the child at the hospital following birth.
Yes
No
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j.
He offered to pay for an abortion/medical expenses.
Yes
No
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k. He paid for birth related expenses.
Yes
No
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l.
He claimed the child on tax returns.
Yes
No
Don't Know
m. He has provided food, clothing, gifts or financial
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support for the child.
Yes
No
If Yes, explain in Section IV
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n. He lived with the child.
Yes
No
If Yes, explain in Section IV
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o. He visited the child.
Yes
No
If Yes, explain in Section IV
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p. The child resembles him.
Photo attached
Yes
No
If Yes, explain in Section IV
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q. There are witnesses to my relationship with him.
Yes
No
(If Yes, list names and addresses and briefly describe relevant facts known by each under Section IV)
Affidavit in Support of Establishing Paternity
Page 2 of 3
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