State of Minnesota County Judicial District: Court File Number: Case Type: In Re the Petition of: , Petitioner and , Petitioner To Adopt: . (child's current name) Adoption District Court Denial of Paternity I, (name of registered man), received a Notice to Registered Putative Father and Notice of Jurisdiction and, being duly sworn upon oath, I state as follows: 1. I was born ___/___/______ (mm/dd/yy) and am _______ years of age . I reside at: (Street address) (City) (State) (Zip) (County) 2. I have been advised ___________________________________ (name of child's mother) is the mother of a male female child born or expected to be born on _________________, 20______, whose name is unknown to me . (child's name) 3. I have registered with the Minnesota Father's Adoption Registry as father of this child. 4. I now deny that I am the child's father. My denial at this time will not subject me to any criminal liability. 5. I enter my appearance in this case and waive service of a summons, other pleading(s), and notice of any further proceedings in this case. ADO102 State ENG Rev 7/15 www.mncourts.gov/forms Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com I have been sworn and state under oath I have read and understand this form. The facts it contains are true and correct to the best of my knowledge. I have signed this document freely and voluntarily. Dated: Signature: Sign only in presence of notary or court clerk Print Name: Street Address: City/State/Zip: Telephone: (______) Email Address: Sworn/affirmed before me this of Notary Public/Court Deputy , 20 ADO102 State ENG Rev 7/15 www.mncourts.gov/forms Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com