IN THE COMMON PLEAS COURT OF LICKING COUNTY, OHIO DIVISION OF DOMESTIC RELATIONS CASE NO. VS. AFFIDAVIT STATE OF OHIO, COUNTY OF LICKING, SS: Mother of is whose date of birth , being first duly cautioned and sworn deposes and says that (are) the only person (s) with whom she has had sexual intercourse within six weeks of the conception of her child. She further states that she was not married to someone else at the birth of her child or within 300 days of the birth and that no one else other than the person listed above signed the child's birth certificate nor, to the best of her knowledge, did any other person except the above named individuals sign any document acknowledging the child as his. CAUTION: READ THIS BEFORE SIGNING! UNTRUE STATEMENTS ON THIS AFFIDAVIT ARE CONSIDERED AS FALSIFICATION AND SUBJECT YOU TO CONTEMPT OF COURT AND POSSIBLE INCARCERATION. FALSIFICATION INCLUDES A FAILURE TO NAME ALL MEN WITH WHOM YOU HAD SEXUAL INTERCOURSE AT, OR AROUND, THE TIME YOU BECAME PREGNANT WITH THE CHILD. Sworn to before me and subscribed in my presence this day of , 20 Notary Public American LegalNet, Inc. www.USCourtForms.com