AFFIDAVIT IN SUPPORT OF ESTABLISHING PATERNITY Petitioner: Name (first, middle, last) Social Security Number IV-D Case: Respondent: Name (first, middle, last) Social Security Number Non-IV-D Case: [ [ [ [ [ [ ] ] ] ] ] ] TANF IV-E Foster Care Medicaid Only Former Assistance Never Assistance File Stamp Responding IV-D Case Identifier Responding Tribunal Number Initiating IV-D Case Identifier Initiating Tribunal Number A Separate Affidavit Is Required for Each Child Needing Paternity Established. SECTION 1 I, Name (first, middle, last) 1. I am the [ ] natural mother of the child named below: [ ] natural father [ ] other; explain in Section IV (first, middle last) , on oath, under penalty of perjury depose and allege: Child's Full Legal Name Child's Date of Birth (Month, Day, Year) Place of Birth (City, County, State) Date Mother Got Pregnant (Month, Year) Full Term Pregnancy [ ] Yes [ ] No (If No, explain) Where Mother Got Pregnant (City, County, State) Mother's Maiden Name (first, middle, last) 2. The child was conceived as a result of sexual intercourse between and me during the time stated above. Name (first, middle, last) [ ] Yes (Attached certified copy) [ ] No 3. a. A man is named as the father on the child's birth certificate. If Yes, the man's name and address are: b. A man was married to the natural mother, and the child's birth occurred within a year of the end of the marriage. If Yes, the man's name and address are: [ ] Yes [ ] No Date marriage ended (Month, Day, Year) c. A man signed an acknowledgment of paternity before an acknowledgment became a legal finding of paternity under State law. A man acted as and presented himself to be the child's father. If Yes, the man's name and address are: [ ] Yes (Attached certified copy) [ ] No d. [ ] Yes [ ] No e. Genetic tests were completed to determine the biological father of the child. If Yes, attach results. [ ] Yes [ ] No Affidavit in Support of Establishing Paternity OMB 0970 ­ 0085 Expiration Date: 05/31/2014 Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT IN SUPPORT OF ESTABLISHING PATERNITY, PAGE 2 SECTION II (TO BE COMPLETED BY MOTHER ONLY) 1. Initiating IV-D Case Identifier I had sexual intercourse with another man (other than the man I am naming as the child's natural father) during the time 30 days before or 30 days after the child was conceived. [ ] Yes [ ] No (If Yes, complete the following). a. The name(s) and address(es) of the other man/men: b. The other man/men are biologically related to the man I am naming as the child's natural father. [ ] Yes [ ] No. If Yes, explain the biological relationship (e.g., brother, cousin, uncle, etc.) I do not believe the other man/men is/are the father because: c. 2. I was married at the time of this child's birth a. [ ] Yes [ ] No (If Yes, complete the following) Husband's name (first, middle, last) and last known address: b. Explain why the husband is not the father of this child and attach all appropriate documents, including divorce decree, genetic test results and prior findings of non-paternity, if any: 3. a. b. c. d. e. Name (first, middle, last) We lived together. is the father of this child. The following facts support my allegations of paternity: [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] No [ ] No [ ] No [ ] No Dates: Location To I have told welfare officials that he is the father of this child. I told him that he was the father of the child. He is named as the father on the birth certificate. He signed an acknowledgment of paternity before an acknowledgment became a legal finding of paternity under State law. He admitted being the father of the child. He sent cards/letters regarding the pregnancy and/or about the child. He was present at the birth of the child. He visited the child at the hospital following birth He offered to pay abortion expenses. He offered to pay medical expenses. He paid for birth related expenses. He claimed the child on tax returns. He has provided food, clothing, gifts or financial support for the child. He lived with the child. He visited the child. The child resembles him. [ ] Photo attached There are witnesses to my relationship with him. [ ] Certified Copy Attached [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] Yes [ ] No [ ] No [ ] No [ ] No [ ] No [ ] No [ ] No [ ] No [ ] No [ ] No [ ] No [ ] No [ ] No [ ] No [ ] Certified Copy Attached [] Copies Attached f. g. h. i. j. k. l. m. n. o. p. q. r. [] Don't Know If Yes, explain in Section IV If Yes, explain in Section IV If Yes, explain in Section IV If Yes, explain in Section IV (If Yes, list names and addresses and briefly describe relevant facts known by each under Section IV) Affidavit in Support of Establishing Paternity Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT IN SUPPORT OF ESTABLISHING PATERNITY, PAGE 3 SECTION III (TO BE COMPLETED BY FATHER ONLY) The following facts support my belief and statements that I am the father of this child: a. b. c. d. The mother and I lived together. The mother told me that I am the father of the child. I am named as the father on the birth certificate. I signed an acknowledgment of paternity before an acknowledgment became a legal finding of paternity under State law. [ ] Yes [ ] Yes [ ] Yes [ ] Yes Initiating IV-D Case Identifier [ ] No [ ] No [ ] No [ ] No Dates: Location To [ ] Certified Copy Attached [ ] Certified Copy Attached e. f. g. h. i. j. k. l. m. n. o. I was present at the birth of the child. [ ] Yes [ ] No I visited the child at the hospital following birth [ ] No [ ] Yes I offered to pay abortion expenses. [ ] No [ ] Yes I offered to pay medical expenses. [ ] No [ ] Yes I paid for birth related expenses. [ ] No [ ] Yes I claimed the child on tax returns. [ ] No [ ] Yes I have provided food, clothing, gifts or financial support for the child. [ ] Yes [ ] No If Yes, explain in Section IV I lived with the child. [ ] Yes [ ] No If Yes, explain in Section IV I visited the child. [ ] Yes [ ] No If Yes, explain in Section IV If Yes, explain in Section IV [ ] Yes The child resembles me. [ ] Photo attached [ ] No There are witnesses to my relationship with the [ ] Yes child's mother [ ] No (If Yes, list names and addresses and briefly describe relevant facts known by each under Section IV) SECTION IV ­ OTHER PERTINENT INFORMATION (including detailed explanations for "Yes" responses in Section II or Section III above) [] Continued On Attached Shee