Affidavit Of Birth Mother
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Affidavit Of Birth Mother Form. This is a New Hampshire form and can be use in Probate Court Statewide.
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Tags: Affidavit Of Birth Mother, NHJB-2189-FP, New Hampshire Statewide, Probate Court
THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
http://www.courts.state.nh.us
Court Name:
Case Name:
Case Number:
(if known)
AFFIDAVIT OF BIRTH MOTHER (RSA 170-B)
I,
, of
under oath, do state the following: (Please check all appropriate boxes.)
1. I am the mother of
,
, born on
,
in (city, state)
2. The name of the child’s father is
;
his mailing address is
3. I do not wish to identify the name of the child’s father.
4. Birth mother’s current marital status:
Single
Married
Divorced
Widowed
If married, divorced or widowed, name of spouse
If applicable, date of marriage
date of divorce
5. I am not, and have not, lived with any man who is providing or has provided support to me or
my child, and who is holding himself out to be the child’s father.
6. I am living with, or have lived with,
, who is providing or
has provided support to me or my child, and who is holding himself out to be the child’s father.
His mailing address is:
7. To the best of my knowledge, no person holds himself out to be the father of my child named
above, or has filed a claim with the Child Support Services, Division of Health and Human
Services.
8. In order for the Division of Health and Human Services to complete a search of its putative
father’s registry, I verify that the only names I have ever used since my birth are as follows:
(Please print the full name used.)
Date
Birth Mother’s signature
, County of
State of
This instrument was acknowledged before me on
My Commission Expires
Affix Seal, if any
NHJB-2189-FP (10/01/2006)
(formerly AOC-082F-003 and AOC-082F-008)
by
Signature of Notarial Officer / Title
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