Commonwealth of Massachusetts VOLUNTARY ACKNOWLEDGMENT OF PARENTAGE R-130-02112011 This is a legal document. Print or type in permanent black ink. We voluntarily sign this acknowledgment to establish the child's paternity. We understand that this acknowledgment will be filed with the child's birth certificate and the names of both parents will be on the child's birth certificate. We further understand that this acknowledgment is a legal document with the same binding effect as a court judgment of paternity. We acknowledge that we are the biological parents of the following CHILD: Social Security # (if assigned): Full name to appear on the birth certificate: If amending, name as it now appears: Birthplace: City/Town First, Middle, Last First, Middle, Last State Date of Birth (Month spelled out, Day, Year) Social Security # Sex (M/F) MOTHER Full name to appear on the birth certificate: Residence: No. & Street Name First, Middle, Last City/Town Birthplace: City/Town State Surname at my Birth or Adoption Zip Code State (Country if not U.S.) Date of Birth (Month spelled out, Day, Year) Check one: I swear or affirm that when this child was born or within 300 days of the child's birth, I was not married. I swear or affirm that when this child was born or conceived, I was married to someone other than the father of this child. I understand that this form will not add the father to the birth certificate unless accompanied by an Affidavit of Non-Paternity or Affidavit of Non-Parentage signed by that spouse or unless the court has determined that the spouse to whom I was married is not the child's legal parent. I understand that signing this form is voluntary and that paternity is established as of the date that this form is completed by both parents and properly filed at the offices of the city or town clerk where the child was born or the State Registry of Vital Records and Statistics. I have read and understand the information on this form, and on the Notice of Rights and Responsibilities: Voluntary Acknowledgment of Parentage, including the information on the process for rescinding (canceling) this acknowledgment of paternity. I understand the rights and responsibilities that result when both parents sign this form. I hereby swear or affirm under the penalties of perjury that the information above is true to the best of my knowledge and belief. On this ___________ day of ____________________, _________ before me, the undersigned notary public, personally appeared ________________________________________________ who proved to me through satisfactory evidence of identification, which was or were ___________________________________________________ to be the person whose name is signed on this document and who swore or affirmed to me that the contents of the document are truthful and accurate to the best of her knowledge and belief and that she signed Notary Public this form voluntarily for its stated purpose. Social Security # - Signature of Mother Form read in FATHER Full name to appear on the birth certificate: Residence: No. & Street Name First, Middle, Last City/Town Birthplace: City/Town State Surname at my Birth or Adoption Zip Code State (Country if not U.S.) Date of Birth (Month spelled out, Day, Year) I understand that signing this form is voluntary and that paternity is established as of the date that this form is completed by both parents and properly filed at the offices of the city or town clerk where the child was born or the State Registry of Vital Records and Statistics. I have read and understand the information on this form, and on the Notice of Rights and Responsibilities: Voluntary Acknowledgment of Parentage, including the information on the process for rescinding (canceling) this acknowledgment of paternity. I understand the rights and responsibilities that result when both parents sign this form. I hereby swear or affirm under the penalties of perjury that the information above is true to the best of my knowledge and belief. On this ___________ day of ____________________, _________ before me, the undersigned notary public, personally appeared ________________________________________________ who proved to me through satisfactory evidence of identification, which was or were ___________________________________________________ to be the person whose name is signed on this document and who swore or affirmed to me that the contents of the document are truthful and accurate to the best of his knowledge and belief and that he signed Notary Public this form voluntarily for its stated purpose. American LegalNet, Inc. www.FormsWorkFlow.com Signature of Father Form read in Notice of Rights and Responsibilities: Voluntary Acknowledgment of Parentage What Does It Mean If You Sign this Form? The "Voluntary Acknowledgment of Parentage" form establishes your child's paternity, after both parents have signed it and the State Registry of Vital Records and Statistics has accepted it for legal registration. "Paternity" is the legal relationship between a child and father. "Voluntary" means that you both freely choose to sign this form. If a child's parents are not married to each other, paternity is established only by: 1. 2. 3. Completing an acknowledgment form at the hospital where the child was born prior to birth certificate registration, or Completing the form at the State Registry of Vital Records and Statistics, the clerk's office for the city or town where the child was born, or at the Probate and Family Court, or Filing a paternity action in court. Otherwise, your child may have no father under the law, and the father's name will not go on the birth certificate. DO NOT SIGN THIS FORM IF EITHER OF YOU IS NOT SURE, OR HAS ANY DOUBT WHO THE FATHER IS. If either of you is not sure who the father is, have paternity testing and get the results before signing the acknowledgment. DO NOT SIGN THIS FORM IF YOU DO NOT UNDERSTAND IT If you have any questions about the legal consequences of signing the form, consult an attorney before signing. When you sign this form, you will be confirming that you have read and understand both the acknowledgment form and this Notice of Rights and Responsibilities. If you prefer to read the form in another language, ask for a translated form or a translator to assist you. Paternity is established as of the date both parents have signed the acknowledgment, if it is properly completed and filed. Sixty (60) days or less after both parents sign the form, i