Illinois Voluntary Acknowledgment of Paternity Instructions: PRINT in BLACK ink. Press firmly and use a ballpoint pen. Do not cross out words or make corrections or your form will be rejected. If you make a mistake, ask for a new form. See additional instructions on the reverse side of this form. Read carefully and complete all information before signing this form. Call the Child Support Customer Service Call Center at 1-800-447-4278 if you have questions. Questions about the birth certificate must be directed to the Illinois Department of Public Health, Division of Vital Records, at www.idph.state.il.us/vitalrecords or 217-782-6554. Child’s First Name Middle Name Last Name (same as on birth certificate) Date of Birth (mm/dd/yy) Place of Birth – Hospital Name City/State Father’s Name (first/middle/last) Date of Birth (mm/dd/yy) Place of Birth (city/state) Address City/State/Zip Sex (circle) M F Social Security Number Mother’s Name (first/middle/last) Address Mother’s Maiden Name Date of Birth (mm/dd/yy) Place of Birth (city/state) City/State/Zip Social Security Number Were you married to a man other than the biological father when this child was conceived? Yes ________ No __________ By signing, I: 1. 2. 3. 4. 5. 6. 7. Understand that this is a legal document. I understand that when the Voluntary Acknowledgment of Paternity (hereafter called VAP) is signed and witnessed, it is the same as a court order determining the legal relationship between a father and child. Understand that if I am a minor, I have the right to sign and have this form witnessed without my guardian’s permission. I understand that when the parents are minors, paternity is not conclusive until six months after the younger of the parents turns 18. Understand that both parents have the right to all notices of any adoption proceedings. Understand my responsibility to provide financial support for the child that may include child support and medical support starting from the child’s birth until the child is at least 18 years old. Understand that this VAP does not give custody or visitation to the father. However, this gives the father the right to ask the court for custody or visitation. Understand that either the mother or father may withdraw the action by signing a Rescission of VAP. The Rescission must be signed and received by the Department within 60 days signing the VAP or the date of a proceeding relating to the child, whichever occurs earlier. Have read the instructions on the back of this form, been provided an oral explanation about the VAP and understand my rights and responsibilities created and waived by signing this form. Oral explanations can be heard by calling 1-800-447-4278. I ALSO UNDERSTAND THAT I CAN REQUEST A GENETIC TEST REGARDING THE CHILD’S PATERNITY, AND THAT BY SIGNING THIS FORM I AM GIVING UP MY RIGHT TO A GENETIC TEST. Father’s Signature Mother’s Signature Print Name of Father Print Name of Mother Witness’ Signature Witness’ Signature Print Name of Witness Print Name of Witness Witness Address Witness Address Witness’ Telephone #: Witness’ Telephone #: Date Parties Signed Date Parties Signed Original – Send to HFS/ACU, 110 W Lawrence, Springfield, IL 62704, if signed in hospital. Send original and first copy to HFS if signed outside hospital. HFS 3416B (R-2-09) _______For Official Use Only ________________________________________________________________________________________________ Case # Docket # CP RIN NCP RIN Child RIN American LegalNet, Inc. www.FormsWorkFlow.com Illinois Voluntary Acknowledgment of Paternity Instructions: PRINT in BLACK ink. Press firmly and use a ballpoint pen. Do not cross out words or make corrections or your form will be rejected. If you make a mistake, ask for a new form. See additional instructions on the reverse side of this form. Read carefully and complete all information before signing this form. Call the Child Support Customer Service Call Center at 1-800-447-4278 if you have questions. Questions about the birth certificate must be directed to the Illinois Department of Public Health, Division of Vital Records, at www.idph.state.il.us/vitalrecords or 217-782-6554. Child’s First Name Middle Name Last Name (same as on birth certificate) Date of Birth (mm/dd/yy) Place of Birth – Hospital Name City/State Father’s Name (first/middle/last) Date of Birth (mm/dd/yy) Place of Birth (city/state) Address City/State/Zip Sex (circle) M F Social Security Number Mother’s Name (first/middle/last) Address Mother’s Maiden Name Date of Birth (mm/dd/yy) Place of Birth (city/state) City/State/Zip Social Security Number Were you married to a man other than the biological father when this child was conceived? Yes ________ No __________ By signing, I: 1. 2. 3. 4. 5. 6. 7. Understand that this is a legal document. I understand that when the Voluntary Acknowledgment of Paternity (hereafter called VAP) is signed and witnessed, it is the same as a court order determining the legal relationship between a father and child. Understand that if I am a minor, I have the right to sign and have this form witnessed without my guardian’s permission. I understand that when the parents are minors, paternity is not conclusive until six months after the younger of the parents turns 18. Understand that both parents have the right to all notices of any adoption proceedings. Understand my responsibility to provide financial support for the child that may include child support and medical support starting from the child’s birth until the child is at least 18 years old. Understand that this VAP does not give custody or visitation to the father. However, this gives the father the right to ask the court for custody or visitation. Understand that either the mother or father may withdraw the action by signing a Rescission of VAP. The Rescission must be signed and received by the Department within 60 days signing the VAP or the date of a proceeding relating to the child, whichever occurs earlier. Have read the instructions on the back of this form, been provided an oral explanation about the VAP and understand my rights and responsibilities created and waived by signing this form. Oral explanations can be heard by calling 1-800-447-4278. I ALSO UNDERSTAND THAT I CAN REQUEST A GENETIC TEST REGARDING THE CHILD’S PATERNITY, AND THAT BY SIGNING THIS FORM I AM GIVING UP MY RIGHT TO A GENETIC TEST. Father’s Signature Mother’s Signature Print Name of Father Print Name of Mother Witness’ Signature Witness’ Signature Print Name of Witness Print Name of Witness Witness Address Witness Address Witness’ Telephone #: Witness’ Telephone #: Date Parties Signed Date Parties Signed First Copy – Hospital Copy (if signed in hospital). The original and this copy are sent to HFS/ACU if signed outside hospital. HFS 3416B (R-2-09) _______For Official Use Only ________________________________________________________________________________________________ Case # Docket # CP RIN NCP RIN Child RIN American LegalNet, Inc. www.FormsWorkFlow.com Illinois Voluntary Acknowledgment of Paternity Instructions: PRINT in BLACK ink. Press firmly and use a ballpoint pen. Do not cross out words or make corrections or your form will be rejected. If you make a mistake, ask for a new form. See additional instructions on the reverse side of this form. Read carefully and complete all information before signing this form. Call the Child Support Customer Service Call Center at 1-800-447-4278 if you have questions. Questions about the birth certificate must be directed to the Illinois Department of Public Health, Division of Vital Records, at www.idph.state.il.us/vitalrecords or 217-782-6554. Child’s First Name Middle Name Last Name (same as on birth certificate) Date of Birth (mm/dd/yy) Place of Birth – Hospital Name City/State Father’s Name (first/middle/last) Date of Birth (mm/dd/yy) Place of Birth (city/state) Address City/State/Zip Sex (circle) M F Social Security Number Mother’s Name (first/middle/last) Address Mother’s Maiden Name Date of Birth (mm/dd/yy) Place of Birth (city/state) City/State/Zip Social Security Number Were you married to a man other than the biological father when this child was conceived? Yes ________ No __________ By signing, I: 1. 2. 3. 4. 5. 6. 7. Understand that this is a legal document. I understand that when the Voluntary Acknowledgment of Paternity (hereafter called VAP) is signed and witnessed, it is the same as a court order determining the legal relationship between a father and child. Understand that if I am a minor, I have the right to sign and have this form witnessed without my guardian’s permission. I understand that when the parents are minors, paternity is not conclusive until six months after the younger of the parents turns 18. Understand that both parents have the right to all notices of any adoption proceedings. Understand my responsibility to provide financial support for the child that may include child support and medical support starting from the child’s birth until the child is at least 18 years old. Understand that this VAP does not give custody or visitation to the father. However, this gives the father the right to ask the court for custody or visitation. Understand that either the mother or father may withdraw the action by signing a Rescission of VAP. The Rescission must be signed and received by the Department within 60 days signing the VAP or the date of a proceeding relating to the child, whichever occurs earlier. Have read the instructions on the back of this form, been provided an oral explanation about the VAP and understand my rights and responsibilities created and waived by signing this form. Oral explanations can be heard by calling 1-800-447-4278. I ALSO UNDERSTAND THAT I CAN REQUEST A GENETIC TEST REGARDING THE CHILD’S PATERNITY, AND THAT BY SIGNING THIS FORM I AM GIVING UP MY RIGHT TO A GENETIC TEST. Father’s Signature Mother’s Signature Print Name of Father Print Name of Mother Witness’ Signature Witness’ Signature Print Name of Witness Print Name of Witness Witness Address Witness Address Witness’ Telephone #: Witness’ Telephone #: Date Parties Signed Date Parties Signed Second Copy – Parent’s Copy HFS 3416B (R-2-09) _______For Official Use Only ________________________________________________________________________________________________ Case # Docket # CP RIN NCP RIN Child RIN American LegalNet, Inc. www.FormsWorkFlow.com Illinois Voluntary Acknowledgment of Paternity Instructions: PRINT in BLACK ink. Press firmly and use a ballpoint pen. Do not cross out words or make corrections or your form will be rejected. If you make a mistake, ask for a new form. See additional instructions on the reverse side of this form. Read carefully and complete all information before signing this form. Call the Child Support Customer Service Call Center at 1-800-447-4278 if you have questions. Questions about the birth certificate must be directed to the Illinois Department of Public Health, Division of Vital Records, at www.idph.state.il.us/vitalrecords or 217-782-6554. Child’s First Name Middle Name Last Name (same as on birth certificate) Date of Birth (mm/dd/yy) Place of Birth – Hospital Name City/State Father’s Name (first/middle/last) Date of Birth (mm/dd/yy) Place of Birth (city/state) Address City/State/Zip Sex (circle) M F Social Security Number Mother’s Name (first/middle/last) Address Mother’s Maiden Name Date of Birth (mm/dd/yy) Place of Birth (city/state) City/State/Zip Social Security Number Were you married to a man other than the biological father when this child was conceived? Yes ________ No __________ By signing, I: 1. 2. 3. 4. 5. 6. 7. Understand that this is a legal document. I understand that when the Voluntary Acknowledgment of Paternity (hereafter called VAP) is signed and witnessed, it is the same as a court order determining the legal relationship between a father and child. Understand that if I am a minor, I have the right to sign and have this form witnessed without my guardian’s permission. I understand that when the parents are minors, paternity is not conclusive until six months after the younger of the parents turns 18. Understand that both parents have the right to all notices of any adoption proceedings. Understand my responsibility to provide financial support for the child that may include child support and medical support starting from the child’s birth until the child is at least 18 years old. Understand that this VAP does not give custody or visitation to the father. However, this gives the father the right to ask the court for custody or visitation. Understand that either the mother or father may withdraw the action by signing a Rescission of VAP. The Rescission must be signed and received by the Department within 60 days signing the VAP or the date of a proceeding relating to the child, whichever occurs earlier. Have read the instructions on the back of this form, been provided an oral explanation about the VAP and understand my rights and responsibilities created and waived by signing this form. Oral explanations can be heard by calling 1-800-447-4278. I ALSO UNDERSTAND THAT I CAN REQUEST A GENETIC TEST REGARDING THE CHILD’S PATERNITY, AND THAT BY SIGNING THIS FORM I AM GIVING UP MY RIGHT TO A GENETIC TEST. Father’s Signature Mother’s Signature Print Name of Father Print Name of Mother Witness’ Signature Witness’ Signature Print Name of Witness Print Name of Witness Witness Address Witness Address Witness’ Telephone #: Witness’ Telephone #: Date Parties Signed Date Parties Signed Third Copy – Parent’s Copy HFS 3416B (R-2-09) _______For Official Use Only ________________________________________________________________________________________________ Case # Docket # CP RIN NCP RIN Child RIN American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing the Illinois Voluntary Acknowledgment of Paternity PURPOSE: The Voluntary Acknowledgment of Paternity (hereafter called VAP) legally establishes the biological father and child relationship (when the biological father is not married to the child’s mother) and allows the biological father’s name to be placed on the birth certificate. The biological father becomes the legal father of the child when the VAP is properly signed and witnessed, creating certain legal rights and responsibilities for the child and the parents. If the mother is or was married to a man who is not the biological father when the child was conceived or born, a Denial of Paternity (hereafter called the Denial) must be signed and witnessed before the mother and biological father may sign the Acknowledgment (refer to instruction 2 below). PLEASE READ ALL PARTS OF THIS FORM, INCLUDING THE INFORMATION REGARDING YOUR RIGHTS AND RESPONSIBILITIES BEFORE COMPLETING THIS FORM. 1. The VAP may not be signed before your child is born. 2. The mother must indicate “yes” or “no” if she is or was married at the time of conception or upon the birth of the child, and the husband/ex-husband is not the biological father. The husband/ex-husband and mother must sign the Denial and the mother and biological father must sign the VAP to establish legal paternity and place the biological father’s name on the birth certificate. If the husband/ex-husband and the mother do not sign the Denial, the husband/ex-husband is presumed to be the father of the child and his name, by law, must be placed on the birth certificate. 3. Each person must sign and date all forms in front of a witness. A witness must be an adult age eighteen or older but cannot be the parents or the child named on the VAP. 4. If you are completing the VAP (and Denial, if necessary) at the hospital when the child is born, hospital staff will add the biological father’s name to the birth certificate. 5. You may complete the VAP (and Denial, if necessary) after you leave the hospital. 6. You may complete the VAP (and Denial, if necessary) for a child born in another state when the biological father was not married to the mother of the child. 7. When the VAP (and Denial, if necessary) is not completed at the hospital, the parents must sign and date the form(s) in front of an adult witness. 8. Send the completed original and second copy to the Department’s: Administrative Coordination Unit (ACU) 110 West Lawrence Street Springfield, Illinois 62704 To ensure that the biological father’s name is placed on the child’s birth certificate, the ACU will then send the completed VAP (and Denial, if necessary) to either the: 1. Illinois Department of Public Health, Division of Vital Records (for Illinois births), or 2. Vital Records Office in affected state (for out of state births) NOTE: Forms that contain errors will be rejected. As a result, paternity is not established and the biological father’s name will not be placed on the birth certificate. FOR MORE INFORMATION about completing the VAP, read the flyer “Two Parents…Give Your Child HOPE.” You may obtain the flyer by asking hospital staff, state and local registrars, county clerks, Department of Human Services offices or Child Support Enforcement offices. You will also be given a child support services application if you are not currently receiving public assistance. Spanish versions are available upon request and on the Department’s website (www.ilchildsupport.com), but may be used for translation purposes only. The Spanish versions are not acceptable as legal documents. Only the English version of the documents may be signed and witnessed. SI LAS PIDE, TENEMOS VERSIONES EN ESPAÑOL DISPONIBLES Y EN EL SITIO DEL DEPARTAMENTO EN EL INTERNET EN (WWW.ILCHILDSUPPORT.COM), PERO SÓLO SE PUEDEN USAR PARA PROPÓSITOS DE TRADUCCIÓN. LAS VERSIONES EN ESPAÑOL NO SON DOCUMENTOS LEGALES ACEPTABLES. SÓLO LA VERSIÓN EN INGLES DEL DOCUMENTO SE PUEDE FIRMAR Y ATESTIGUAR. If you have any questions relating to the child’s birth certificate, please contact the Department of Public Health’s Division of Vital Records at www.idph.state.il.us/vitalrecords or 217-782-6554. If you have any questions relating to completing this form, please call the Child Support Customer Service Call Center at 1-800-4474278. American LegalNet, Inc. www.FormsWorkFlow.com