IN THE CIRCUIT COURT OF THE ___________ JUDICIAL CIRCUIT IN AND FOR ___________________ COUNTY, FLORIDA JUVENILE DIVISION In the Interest of ) ) ) ) ) Case No. a child SWORN STATEMENT REGARDING IDENTITY OR LOCATION OF FATHER 1. My name is: My address is: 2. I am related to (child) , because I am his/her . 3. I understand that I am answering these questions under oath and from my own personal knowledge and I swear to tell the truth. I understand that this sworn statement will be filed with the court. 4. The mother of the child WAS married to conception of the child. OR at the probable time of The mother of the child WAS NOT married at the probable time of conception of the child. OR I do not know whether or not the mother was married at the probable time of conception of the child. 5. The mother of this child WAS married to birth. OR The mother of this child WAS NOT married at the time of this child's birth. OR I do not know whether the mother of this child was married at the time of this child's birth. 6. The mother of this child WAS living with/cohabiting with time of the probable conception of this child. OR at the at the time of this child's The mother of this child WAS NOT living with/cohabiting with any man at the probable time of conception of this child. OR I do not know whether the mother of this child was living with/cohabiting with any man at the probable time of conception of this child. 7. The mother of this child HAS received payments or promises of child support with respect to this child or because of her pregnancy from . OR The mother of this child HAS NOT received payments or promises of child support with respect to this child or because of her pregnancy from anyone. OR I do not know whether the mother has received any payments. Sworn Statement Regarding Identity Or Location Of Father {8.969} Page 1 of 3 American LegalNet, Inc. www.USCourtForms.com 8. The mother named as the father on the child's birth certificate. OR The mother DID NOT name a father on the child's birth certificate. OR I do not know whether the mother named a father on the child's birth certificate. 9. The mother named applying for public assistance. OR as the father of this child in connection with The mother HAS NOT named anyone as the father of this child in connection with applying for public assistance. OR I do not know whether the mother has named anyone as the father of this child in connection with applying for public assistance benefits. 10. has been named in a paternity case or acknowledged paternity in a jurisdiction where the mother lived at the time of or since the conception of this child or where this child resides or has resided. OR No man has been named in a paternity case or acknowledged paternity of this child in a jurisdiction where the mother lived at the time of or since the conception of this child or where this child resides or has resided. OR I do not know if any man has been named in a paternity suit regarding this child. 11. List the name, date of birth, social security number, and last-known address of any man listed in this sworn statement: Name: Date of birth: Social Security No.: Last-known address: 12. Do you know any other information about the identity or location of any man listed in this sworn statement? Yes No. If so, please give that information: I UNDERSTAND THAT THIS DOCUMENT WILL BE FILED WITH THE COURT. UNDER PENALTY OF PERJURY, I DECLARE THAT I HAVE READ IT AND THAT THE FACTS STATED ARE TRUE. Date: , 20 . _____________________________ Signature Witnessed by , who is an authorized agent of the Department of Children and Family Services and who attests that the person who signed this statement provided proof of identify as indicated: Sworn Statement Regarding Identity Or Location Of Father {8.969} Page 2 of 3 American LegalNet, Inc. www.USCourtForms.com Driver's license, number: Passport, number and country: Resident Alien (Green Card), number: Armed Forces Identification, number: Other: Sworn Statement Regarding Identity Or Location Of Father {8.969} Page 3 of 3 American LegalNet, Inc. www.USCourtForms.com