Print Form Declaration of Paternity with Entry of Appearance Clear Form (Rev. 9/21/07) CCCO 0025 IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, COUNTY DIVISION IN THE MATTER OF NOTICE TO ________________________________________________ PUTATIVE FATHER ________________________________________________ (Street) ________________________________________________ (City) (State) (Zip) } No. _________________________________ DECLARATION OF PATERNITY WITH ENTRY OF APPEARANCE (2769) I, __________________________________________________________________________ state as follows: 1. That I am _____ years of age; that I reside at ______________________________________________________ _______________________ in the County of _______________________, State of _______________________. 2. That I have been advised that ______________________________________________ is the mother of a male female child born on ___________________________________, __________, or expected to be born on or about ______________________________, _________, and that such mother has stated that I am the father of this child. 3. I DECLARE that I am the father of this child. 4. I further understand that the mother of this child wishes to consent to the adoption of the child. I do not consent to the adoption of this child. 5. I understand that in order to establish my parental rights in this child, I must do both of the following: (a) I must return this Declaration of Paternity with Entry of Appearance form to the Clerk of the Circuit Court of Cook County, Illinois, located at Room 1202, Richard J. Daley Center, Chicago, Illinois 60602, within 30 days of receipt of this notice; AND, (b) I must initiate a separate action to establish my paternity of this child pursuant to the Parentage Act of 1984 within 30 days of my receiving this notice, or if the child is not yet born, within 30 days after the birth of the child. * Note: You may also be required to register with the Putative Father Registry (750 ILCS 50/12d) within 30 days of the child's birth in order to establish parental rights in the child. For information call 866-737-3237. 6. I hereby enter my appearance in the above entitled cause, and request notice of the birth of the child, and date of birth if not yet born. _________________________________________________ Signature OATH Under penalties for perjury provided by Section 1-109 of the Code of Civil procedure I state that I have read and understand this Declaration of Paternity with Entry of Appearance. The facts that it contains are true and correct to the best of my knowledge, and I understand that by signing this document I admit paternity. I have signed this document as my free and voluntary act. Dated:___________________________, _________ Signature: _____________________________________ _________________________________________________ Print Name DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS