PATERNITY NOTIFICATION AFFIDAVIT
PATERNITY NOTIFICATION AFFIDAVIT
Putative Father's Name: __________________Biological Mother's Name:_____________________
PATERNITY NOTIFICATION AFFIDAVIT, completed by ( )Biological Mother ( ) Legal Guardian
This form is REQUIRED to establish paternity for the child listed based on DNA genetic testing with a minimum Paternity Index of 2,000 to 1. Take this information to the Attorney of your choice to create an enforceable document based on your state laws with emphasis on statutes for perjury, fraud and misrepresentation.
Child's Name on Birth Certificate:____________________________________________ Date of Birth:___/____/____
Child was conceived in: City, State:________________________________________________________________
Hospital where child was born:__________________________________________
City, State:__________________
Date of Conception: ___/___/___ ,
Original Est. Delivery Date: __/__/__ Length of pregnancy at
birth (gestational age in weeks)____________
Marital Status at child's birth: Mother:_________________________ Putative Father: ________________________
If biological mother was married at birth, to whom?:_______________________________________
POSSIBLE FATHER(s):
Is the putative father "the only possible biological father of the child?"__________________ Fill in YES or NO
Did the biological Mother have sexual intercourse with anyone other than the putative father within 60 days of becoming pregnant? _____________ Fill in YES or NO
If so, name:______________________________________ Address:_______________________________________
If so, name:______________________________________ Address:_______________________________________
Did the biological mother inform
the listed possible fathers in writing, of this child? ( ) Yes ( )
No
If so, when and attach proof? ___________________________If not, why not?
____________________________
_______________________________________________________________________________________________
Has the Biological Mother ever named anyone else as the father of this child? ( ) Yes ( ) No
If yes, name:_________________________________Address:____________________________________________
If yes, name:_________________________________Address:____________________________________________
Has DNA paternity testing ever been
done on this putative father for this child?
( )
Yes ( ) No
What were the results?_______________________Paternity Index is_____________%_
(Attach copy of results)
Has DNA paternity testing ever been
done on any other male for this child ? ( ) Yes ( ) No,
What were the results?_______________________Paternity Index is_____________%_ (Attach copy of results)
Personally appeared before the undersigned officer, duly authorized to administer oaths, the undersigned who states under oath that the foregoing statements are true and correct. I understand that medical tests will be required to confirm actual paternity for the above child. I will cooperate with genetic testing and all legal actions to establish paternity for the child.
So sworn and affirmed,
Mother / Guardian's Signature:_________________________________ SSN _____-____-_____ Date:____/____/____
Notary Public Signature: __________________________ Commission Expiration Date:____/____/_____
NOTARY SEAL:
Page 2 for back of form
(PATERNITY NOTIFICATION AFFIDAVIT )
AGREEMENT & AFFIDAVIT
ESTABLISHING PATERNITY FOR THE CHILD LISTED
I acknowledge that I am the biological mother or legal guardian of the child listed in this Affidavit. This Paternity Acknowledgment Affidavit has been given of my own free will and volition, and I understand that under the Laws of the State of __________, and at some time in the future, I may be liable to furnish support for the child named herein, until said child has emancipated.
I understand that the child(ren) and I will be required to submit to genetic testing for paternity determination, and am so willing to cooperate, to establish paternity for the child. Except for legally adopted children and certain cases of births resulting from artificial insemination. See Paternity Testing section for more information.
PATERNITY TESTING: If paternity has not been determined by genetic testing, testing will be required to determine paternity. If the putative father is the biological father, the biological mother or legal guardian will have right of action for child support except for non-adopted children and certain pregnancies resulting from unauthorized artificial insemination. In all cases of artificial insemination, the mother or legal guardian must provide copy of notarized written consent to the procedure, signed by the biological mother, the putative father and the treating physician to have right of action for child support.
COST OF TESTING: Initial Fees for genetic testing will be split on a 50 percent basis by the biological mother or legal guardian and the putative father. If the putative father is not the biological father, he shall be reimbursed in full by the initiating party for all costs associated with defending the false allegation of paternity.
RELEASE OF SUPPORT:
If any of the following conditions apply to the putative father, he shall be released from all responsibility for the child, including child support, arrears and other expenses:
PROOF OF NON-PATERNITY: If the putative father meets any of the criteria above for release of support, he will receive an official order of non-paternity and full release of all obligations for the child listed on this form.
PATERNITY NOTIFICATION AFFIDAVIT form created by Carnell A Smith
Revised 1/09/2002
Paternity Fraud is a crime, crime does NOT PAY and neither should the victim!