Superior Court of Washington County of In re Parentage: Petitioner, and Respondent, and No. Declaration of a Party to the Action to Establish Parentage (Parentage) (DCLR) Respondent, and Child(ren) over the age of 2. I. Declaration (Name) ___________________________________ Declares: 1.1 I am the parent of the child (name) ___________________________ , born on (date) ___________________ because I: A. [ ] am the birth mother. B. [ ] legally adopted the child. C. [ ] signed an affidavit and filed the affidavit and physician’s certificate with the Washington State Registrar of Vital Statistics within ten days after the birth of the child born through assisted reproduction. D. [ ] consented to assisted reproduction by my spouse or domestic partner. E. [ ] asserted in a valid surrogate parentage contract that I am the intended parent of the child. F. [ ] signed a Paternity Acknowledgment. G. [ ] am an alleged parent because within the period from (date) _________________ to (date) ____________________ I had sexual intercourse with (name) ___________________ and I believe I am the father of the child. Declaration of Party (DCLR) - Page 1 of 6 WPF PS 01.0150 (06/2012) – Chapter 26.26 RCW American LegalNet, Inc. www.FormsWorkFlow.com H. [ ] am a presumed parent because (Select all that apply): [ ] (Name) _______________________ and I are or were married to each other or in a domestic partnership with each other and this child was born during the marriage or domestic partnership. [ ] (Name) ________________________ and I were married to each other or in a domestic partnership with each other and this child was born within three hundred days after the marriage or domestic partnership was terminated by death, annulment, dissolution, legal separation, or declaration of invalidity. [ ] Before the birth of this child, (name) ________________________ and I married each other or entered into a domestic partnership with each other in apparent compliance with the law, even if the attempted marriage or domestic partnership is, or could be declared invalid and this child was born during the invalid marriage or invalid domestic partnership or within three hundred days after its termination by death, annulment, dissolution, legal separation, or declaration of invalidity. [ ] After the birth of this child, (name) __________________________ and I married each other or entered into a domestic partnership with each other in apparent compliance with the law, whether or not the marriage or domestic partnership is or could have been declared invalid, and I voluntarily asserted parentage of the child: [ ] in a record filed with the state registrar of vital statistics; [ ] and I agreed to be named as a parent on this child’s birth certificate; [ ] and I promised in a record to support this child as my own. [ ] The petition in this case was or will be filed or served no later than four years after the birth of this child, and for the first two years of this child’s life, I resided in the same household with this child and openly held out this child as my own, by doing the following: . [ ] I attached more pages that are part of this declaration. 1.2 I believe the other party (name) _____________________ is: (select section A, B, or C. and check the box that applies in that section) A. [ ] a parent because: [ ] she is the birth mother. [ ] he or she legally adopted the child. [ ] she signed an affidavit and filed the affidavit and physician’s certificate with the Registrar of Vital Statistics within ten days after the birth of the child born through assisted reproduction. [ ] he or she consented to assisted reproduction by me. Declaration of Party (DCLR) - Page 2 of 6 WPF PS 01.0150 (06/2012) – Chapter 26.26 RCW American LegalNet, Inc. www.FormsWorkFlow.com [ ] he or she asserted in a valid surrogate parentage contract that he or she is the parent of the child. [ ] he or she signed a Paternity Acknowledgment. B. [ ] an alleged parent because (Select all that apply): [ ] Within the period from (date) ______________ to (date) ______________ this child was conceived. I had sexual intercourse only with (name) _____________________ within this time period and he must be the father. [ ] Within the period from (date) ______________ to (date) ______________, this child was conceived. I had sexual intercourse with: (name(s)) __________________________________________________________ __________________________________________________________________. Within this period, this child was conceived and one of these men must be the father. C. [ ] a presumed parent because (Select all that apply): [ ] (Name) ________________________ and I are or were married to each other or in a domestic partnership with each other and this child was born during the marriage or domestic partnership. [ ] (Name) ________________________ and I were married to each other or in a domestic partnership with each other and this child was born within three hundred days after the marriage or domestic partnership was terminated by death, annulment, dissolution, legal separation, or declaration of invalidity. [ ] Before the birth of this child, (name) ________________________ and I married each other or entered into a domestic partnership with each other in apparent compliance with the law, even if the attempted marriage or domestic partnership is, or could be declared invalid and this child was born during the invalid marriage or invalid domestic partnership or within three hundred days after its termination by death, annulment, dissolution, legal separation, or declaration of invalidity. [ ] After the birth of this child, (name) __________________________ and I married each other or entered into a domestic partnership with each other in apparent compliance with the law, whether or not the marriage or domestic partnership is or could have been declared invalid, and (name) ____________________________ voluntarily asserted parentage of the child: [ ] in a record filed with the state registrar of vital statistics; [ ] and agreed to be and is named as a parent on this child’s birth certificate; [ ] and promised in a record to support this child as his or her own. [ ] The petition in this case was or will be filed or served no later than four years after the birth of this child, and for the first two years of this child’s life, (name) _________________________ resided in the same household with this child and openly held out this child as his or her own by doing the following: . Declaration of Party (DCLR) - Page 3 of 6 WPF PS 01.0150 (06/2012) – Chapter 26.26 RCW American LegalNet, Inc. www.FormsWorkFlow.com [ ] I attached more pages that are part of this declaration. 1.3 [ ] I am not the parent of the child because: [ ] (name) ______________________ and I neither cohabited nor engaged in sexual intercourse with each other during the probable time of conception, and I never held out this child as my own. [ ] for the first two years of this child’s life, I did not reside in the same household with this child and I did not openly hold this child out as my own. [ ] other: 1.4 [ ] I believe (name) ____________________ is not the parent of this child because: [] (name) ______________________ and I neither cohabited nor engaged in sexual intercourse with each other during the probable time of conception, and (name) ___________________ never held out this child as his own. [] for the first two years of this child’s life, (name) _________________________ did not reside in the same household with this child and did not openly hold out this child as his or her own. [] other: 1.5 [ ] Within the period from (date) ________________ to (date) ____________________, sexual intercourse with (name) ______________________________ occurred in the state of Washington which may have resulted in the conception of this child. 1.6 [ ] This child was not conceived through assisted reproduction. 1.7 Other: II. Military Service [] To the best of my knowledge and belief (name) _____________________________ is not a service member or a dependent of a service member. [] To the best of my knowledge and belief (name) ______________________________ : [] is on active duty in the U.S. armed forces (excluding National Guard and reserves); Declaration of Party (DCLR) - Page 4 of 6 WPF PS 01.0150 (06/2012) – Chapter 26.26 RCW American LegalNet, Inc. www.FormsWorkFlow.com [] [] [] [] [] is on active duty and is a National Guard member or a Reservist residing in Washington; is not on active duty in the U.S. armed forces (excluding National Guard and reserves); is not on active duty and is a National Guard member or a Reservist residing in Washington. other: To the best of my knowledge and belief (name) ___________________________: [] [] [] is a dependent of a resident of Washington who is on active duty and is a National Guard member or a Reservist; is not a dependent of a resident of Washington who is on active duty and is a National Guard member or a Reservist; other: (Add additional pages if necessary.) III. Statement of Non-Representation I have been informed and understand that the attorney for the state of Washington (Attorney General/Prosecutor) does not represent me in this matter. I understand that I have the right to retain my own attorney at any time. IV. Uniform Child Custody Jurisdiction and Enforcement Act Statement During the last five years, this child has lived: [] [] in no place other than the state of Washington and with no person other than the declarant or a named party. in the following places with the following persons (list each place this child lived, including the state of Washington, the dates this child lived there and the names of the persons with whom this child lived. The present addresses of those persons must be listed in the required Confidential Information Form.): Claims to custody or visitation. [] [] I do not know of any person other than a named party who has physical custody of, or claims to have custody or visitation rights to this child. The following persons have physical custody of, or claim to have custody or visitation rights to this child (list their names and the child(ren) concerned below and list their present addresses in the Confidential Information Form. Do not list the responding party.): Involvement in any other proceeding concerning this child: [] [] I have not been involved in any other proceeding regarding this child. I have been involved in the following proceedings regarding this child (list the court, the case number, and the date of the judgment or order): Declaration of Party (DCLR) - Page 5 of 6 WPF PS 01.0150 (06/2012) – Chapter 26.26 RCW American LegalNet, Inc. www.FormsWorkFlow.com Other legal proceedings concerning this child: [] [] I do not know of any other legal proceedings concerning this child. I know of the following legal proceedings which concern this child (list the child concerned, the court, case number and the kind of proceeding): [] Other: I declare under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct. Signed at (city) ________________________, (state) ___________ on (date) ___________________. Signature of Party to this action Print or Type Name Declaration of Party (DCLR) - Page 6 of 6 WPF PS 01.0150 (06/2012) – Chapter 26.26 RCW American LegalNet, Inc. www.FormsWorkFlow.com