State of Minnesota County District Court Judicial District: Court File Number: Case Type: Adoption In Re the Petition of: , Petitioner And , Petitioner To Adopt: . (child's current name) 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: Admission of Paternity and Intent to Claim Parental Rights (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 declare I am the father of the child. 5. I understand the mother wishes to consent to the adoption of this child. 6. I do not consent to the adoption of this child, and I understand I must return this completed form to the court administrator within 30 days of the date I received the Notice to Registered Putative Father and Notice of Jurisdiction. 7. I intend to retain my legal rights with respect to the child, and request to be notified of any further proceedings with respect to custody or adoption of the child. ADO104 State ENG Rev 11/15 www.mncourts.gov/forms Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 8. I understand that, in order to preserve my right to retain an interest in the child, I must start a paternity action under the Parentage Act (Minn. Stat. �� 257.51 to 257.74) within 30 days of the date I received the Notice to Registered Putative Father and Notice of Jurisdiction, or, if the child is not yet born, within 30 days after the birth of the child, unless I am unable to do so. I understand a paternity action is separate from the mailing of this form. 9. I intend to start a paternity action within 30 days of the date I received the Notice to Registered Putative Father. In the paternity action, I must state I am the father of the child for one or more of the reasons stated in Minn. Stat. � 257.55, subd. 1. 10. I enter my appearance in this case. 11. I understand the court will appoint an attorney to represent me at public expense if I timely file this completed form with the court administrator whose address was listed in the Notice to Registered Putative Father and Notice of Jurisdiction and if I complete an application for courtappointed counsel and the court determines I qualify financially for court appointed counsel. DO NOT SIGN UNTIL YOU ARE BEFORE A NOTARY PUBLIC OR COURT ADMINISTRATOR. OATH I have been sworn and say under oath I have read and understand this form. The facts it contains are true and correct to the best of my knowledge. I understand that by signing this document I admit paternity of the child. I have signed this document freely and voluntarily. Sworn/affirmed before me this of , 20 Signature: Signature: Sign only in presence of notary or court clerk Sign only in presence of notary or court clerk Print Name: Print Name: Street Address: Street Address: City/State/Zip: City/State/Zip: Telephone: (______) Telephone: (______) E-mail address: _____________________________ Notary Public/Court Deputy ACKNOWLEDGMENT Pursuant to Minn. Stat. � 549.211, the undersigned acknowledges that costs, disbursements, and reasonable attorney and witness fees may be awarded to the opposing party or parties for actions in bad faith; the assertion of a claim or a defense that is frivolous and that is costly to the other party; the assertion of an unfounded position solely to delay the ordinary course of the proceedings or to harass; or the commission of a fraud upon the Court. Sworn/affirmed before me this of , 20 Signature: Sign only in presence of notary or court clerk Notary Public/Court Deputy Print Name: Street Address: City/State/Zip: Telephone: (______) E-mail address: www.mncourts.gov/forms Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com ADO104 State ENG Rev 11/15