IN THE CIRCUIT COURT IN THE EIGHTEENTH JUDICIAL CIRCUIT IN AND FOR BREVARD COUNTY, FLORIDA. Case No.: IN RE: IN TERMINATION OF PARENTAL RIGHTS PENDING STEPPARENT ADOPTION OF _____________________________________, Minor Child(ren) AFFIDAVIT OF NONPATERNITY I, {full legal name} _________________________________________________, have personal knowledge of the facts stated in this affidavit and certify that the following statements are true: 1. I have been told that {name} ____________________________________, has a child. I do not wish to and shall not establish or claim paternity for this child, whose name is __________________________________________________ and whose date of bir th is _____________________. 2. The child referenced in this affidavit wanot conceived or born while the birth mothers was married to me. I AM NOT MARRIED TO THE BIRTH MOTHER, nor do I intend to marry the birth mother. 3. With respect to the child referenced in this affidavit, I have not provided the birth mother with child support or prebirth support; Ive not provided her with prenatal care or ha assisted her with medical exnses; Ipe have not provided the birth mother or her child or unborn child with support of any kind, nor do I intend to do so. 4. I have no interest in assuming the responsibilities of parenthood for this child. I will not acknowledge in writing that I am the father of this child, or institute court proceedings to establish the child as mine. 5. I do not object to any decision or arrangements the birth mother makes regarding this child, including adoption. 6. I have been told of my right to choose a person who does not have an employment, professional, or personal relationship with the adoption entity or the prospective adoptive parents to be present when this affidavit is executed and to sign as a witness. The witness I selected is{full legal name} ______________________________________________. I WAIVE NOTICE OF ANY AND ALL PROCEEDINGS TO TERMINATE PARENTAL RIGHTS OR FINALIZE AN ADOPTION UNDER CHAPTER 63, FLORIDA STATUTES. I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this consent and waiver and that the punishmentfor knowingly making a false statement includesfines and/or imprisonment. Law 1084 - New 1/2005 American LegalNet, Inc. www.USCourtForms.com>>>> 2Page 2 _______________________________________ Signature Printed Name:_________________________________ Address:______________________________________ City, State, Zip:_________________________________ _____________________________________________ _______________________________________Signature of Witness Signature of Witness Printed Name:__________________________________ Printed Name:____________________________Business Address:_______________________________ Business Address:_________________________City, State, Zip:_________________________________ City, State, Zip:___________________________Home Address:_________________________________ Home Address:___________________________City, State, Zip:_________________________________ City, State, Zip:___________________________Drivers License:________________________________ Drivers License:_________________________State Id Card No:________________________________ State Id Card No:_________________________STATE OF FLORIDA COUNTY OF BREVARD Sworn to or affirmed and signed before me on{dat e} __________________________________, 20_____, by _____________________________________________. _______________________________________ NOTARY PUBLIC or DEPUTY CLERK _______________________________________ Print, type, or stamp commissioned name of [Print, type, or stamp commissioned name of_____Personally known _____Produced Identification _____Type of identification produced ______________________________________. IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW: [
fill in all blanks] I, {full legal name and trade name of nonlawyer} _____________________________________, a nonlawyer, located at {street} __________________________________________________________, {city} ___________________________, {state} ______________, {phone}__________________, helped { Petitioners name} __________________________________, who is the affiant, fill out this fo rm. Law 1084 - New 1/2005 American LegalNet, Inc. www.USCourtForms.com