Acknowledgement Of Paternity (Page 4 of 4) in pdf

LDSS4418

(Rev. 8/98)

(For Official Use Only)

NEW YORK STATE DEPARTMENT OF HEALTH

Hospital Code: ____________________________ (4 DIGIT PFI No.)

NEW YORK STATE OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE

Pursuant to Section 4135b of Public Health Law

Local district birth number: _______________________________

ACKNOWLEDGMENT OF PATERNITY

Local register number: ___________________________

(Please Type or Print with black Ink)

INDICATE, BY CHECKING THE APPROPRIATE BOX, WHERE THE ACKNOWLEDGMENT IS BEING SIGNED:

HOSPITAL

CHILD SUPPORT OFFICE

BIRTH REGISTRAR

OTHER _________________________

INFORMATION ABOUT THE CHILD FOR WHOM THE ACKNOWLEDGMENT OF PATERNITY IS SIGNED:

PRINT CHILD’S FULL NAME AS IT NOW APPEARS ON THE BIRTH CERTIFICATE:

PRINT CHILD’S NAME AS IT WILL APPEAR ON NEW BIRTH CERTIFICATE:

(First) ( Middle.) (Last)

(First) ( Middle.) ( Last)

PLACE OF BIRTH: (Name and Address of Hospital where child was born):

DATE OF BIRTH

SEX

MONTH

DAY

YEAR

FEMALE

MALE

ACKNOWLEDGMENT OF PATERNITY BY FATHER:

I, __________________________________________________________________________ , residing at ______________________________________

First Middle

Last Name

House/Apt. Number and Street

In the City of ___________________________________________________________ , State of ________________ , Zip Code ____________________

my place of birth,

) _________________________________________________ , my date of birth _____/______/_______ ,

(City, State, Or Foreign Country

Month Day Year

Social Security Number: __________________________ , hereby acknowledge that I am the biological father of the child named above.

I UNDERSTAND THAT SIGNING THIS ACKNOWLEDGMENT WILL ESTABLISH THE PATERNITY OF THE CHILD AND HAVE THE SAME FORCE AND EFFECT AS AN

ORDER OF FILIATION ENTERED AFTER A COURT HEARING INCLUDING AN OBLIGATION TO PROVIDE SUPPORT FOR THE CHILD. EXCEPT THAT ONLY IF THIS

ACKNOWLEDGMENT IS FILED WITH THE REGISTRAR WHERE THE BIRTH CERTIFICATE IS FILED WILL THE ACKNOWLEDGMENT HAVE SUCH FORCE AND EFFECT

WITH RESPECT TO INHERITANCE RIGHTS. I HAVE RECEIVED WRITTEN AND ORAL NOTICE OF MY LEGAL RIGHTS AND THE CONSEQUENCES OF SIGNING THE

ACKNOWLEDGMENT OF PATERNITY, AND I UNDERSTAND WHAT THE NOTICE STATES. A COPY OF THE WRITTEN NOTICE HAS BEEN PROVIDED TO ME. I CERTIFY

THAT THE ABOVE INFORMATION IS TRUE.

SIGNATURE: _____________________________________________________________________________________ Date _____/______/_______ ,

Month Day Year

The above named ________________________, signed and affirmed before us this ____ day of _____________ , ____ , that the information contained

herein is true.

__________________________________________________ _______________________________________________________

First Witness

Second Witness

(Witnessed by two people not related to the mother or father.)

ACKNOWLEDGMENT OF PATERNITY BY MOTHER:

I, __________________________________________________________________________ , residing at ______________________________________

First Middle Last Name

House/Apt. Number and Street

In the City of ___________________________________________________________ , State of ________________ , Zip Code ____________________

my place of birth,

) _________________________________________________ , my date of birth _____/______/_______ ,

(City, State, Or Foreign Country

Month Day Year

Social Security Number: __________________________ , hereby consent to the acknowledgment of paternity for my child named above, and

acknowledge that the man named above is the only possible father of my child who was born to me. I state that I was not married at any time during the

pregnancy or when the child was born OR, I state that I was not married when the child was born or at any time during the pregnancy but I have

subsequently married the child’s biological father.

I UNDERSTAND THAT SIGNING THIS ACKNOWLEDGMENT WILL ESTABLISH THE PATERNITY OF THE CHILD AND HAVE THE SAME FORCE AND EFFECT AS AN

ORDER OF FILIATION ENTERED AFTER A COURT HEARING INCLUDING AN OBLIGATION TO PROVIDE SUPPORT FOR THE CHILD. EXCEPT THAT ONLY IF THIS

ACKNOWLEDGMENT IS FILED WITH THE REGISTRAR WHERE THE BIRTH CERTIFICATE IS FILED WILL THE ACKNOWLEDGMENT HAVE SUCH FORCE AND EFFECT

WITH RESPECT TO INHERITANCE RIGHTS. I HAVE RECEIVED WRITTEN AND ORAL NOTICE OF MY LEGAL RIGHTS AND THE CONSEQUENCES OF SIGNING THE

ACKNOWLEDGMENT OF PATERNITY, AND I UNDERSTAND WHAT THE NOTICE STATES. A COPY OF THE WRITTEN NOTICE HAS BEEN PROVIDED TO ME. I CERTIFY

THAT THE ABOVE INFORMATION IS TRUE.

I am currently in receipt of public assistance and/or child support services from a social services district in New York state.

YES If “Yes”, identify the county and address of the social services district, if known: ____________________________________________ .

SIGNATURE: _____________________________________________________________________________________ Date _____/______/_______ ,

Month Day Year

My maiden name is (Last name only): __________________________________________.

The above named ________________________, signed and affirmed before us this ____ day of _____________ , ____ , that the information contained

herein is true.

__________________________________________________ _______________________________________________________

First Witness

Second Witness

(Witnessed by two people not related to the mother or father.)

IMPORTANT NOTICE:

This form must be completed and filed with the registrar of the district in which the birth occurred and in which birth certificate has been or will be filed.

(For Official Use Only)

The above ACKNOWLEDGMENT OF PATERNITY is hereby filed with the registrar of ______________________________________________________

on ________________________ (Date). Registrar :_____________________________________________________________________________________________

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