DECLARATION IN SUPPORT OF ESTABLISHING PARENTAGE File Stamp THIS FORM CONTAINS SENSITIVE INFORMATION 226 DO NOT FILE THIS FORM IN A PUBLIC ACCESS FILE The information on this form may be filed with the petition or pleading and may be disclosed to the parties in the case unless accompanied by a nondisclosure finding/affidavit. If you are not the intended recipient, you are hereby notified that any use, disclosure, distribution, or copying of this form or its contents is strictly prohibited. Personal Information Form for UIFSA 247 311 must be a ttached . Petitioner: IV-D Case: [ ] TANF [ ] IV-E Foster Care Tribal Affiliation (if applicable) [ ] Medicaid Only [ ] Former Assistance Respondent: Legal Name (first, middle, last, suffix) [ ] Never Assistance Non - IV - D Case: [ ] Tribal Affiliation (if applicable) Responding IV-D Case Identifier: NOTE: Responding Tribunal Number: [ ] Nondiscl osure Finding/Affidavit attached [ ] This form sent through EDE Initiating IV-D Case Identifier: Initiating Tribunal Number: DO NOT COMPLETE THIS FORM IF THERE IS AN ORDER OF PARENTAGE002 OR A SIGNED VOLUNTARY ACKNOWLEDGMENT OF PARENTAGE002 A SEPARATE DECLARATION IS REQUIRED FOR EACH CHILD NEEDING PARENTAGE ESTABLISHED. Section I. Declaration: , declare under penalty of perjury: Legal Name (first, middle, last, suffix) 1. Check one: [ ] I am the biological parent of the child named below. Gender: [ ] Female [ ] Male [ ] Other [ ] I am the nonbiological parent of the child named below. Gender: [ ] Female [ ] Male [ ] Other [ ] Other (Explain relationship to the child in section IV.) Child222s legal name (first, middle last, suffix): Date conception occurred (month, year): Location where child was conceived (city, county, state): Full term pregnancy: [ ] Yes [ ] No 2. The respondent is the [ ] biological parent [ ] nonbiological parent of the child named above. Declaration in Support of Establishing Parentage OMB 0970-0085 Expiration Date: Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com DECLARATION IN SUPPORT OF ESTABLISHING PARENTAGE , PAGE 2002 Section I. Declaration (Continued) : 3.003 The child was conceived as a result of sexual intercourse between and Legal Name (first, middle, last, suffix)002 during the time stated above.002 Legal Name (first, middle, last, suffix)002 (NOTE: If #3 is not applicable, please provide all pertinent information regarding the conception of the child in section IV.)002 4.003 The following facts support a presumption of parentage: If additional space is needed, use section IV. a.003 The biological mother was married, and the child222s birth [ ] Yes [ ] No (If yes, attach documentation.) occurred during the marriage or within 300 days after the Date marriage began: marriage legally ended. (month, day, year) If yes, and the mother222s spouse/former spouse is not the person Date marriage legally ended: named as respondent in this Declaration, provide the (month, day, year) spouse/former spouse222s name, address, and gender, and Tribunal that issued order legally ending the marriage: explain why he/she is not the child222s parent: b.003 A person acted as, and presented herself/himself to be, the child222s [ ] Yes [ ] No parent. If yes, and he/she is not the person named as the respondent in this Declaration, provide the individual222s name, address, and gender, and explain why the individual is not the child222s parent: c.003 A genetic test ordered/administered by a court or a IV-D agency [ ] Yes [ ] No (If yes, attach results.) to determine the other biological parent of the child indicates a probability of parentage of %. If yes, and the individual tested is not the respondent named in this Declaration, provide the individual222s name, address, and gender, and explain why the individual is not the child222s parent: Declaration in Support of Establishing Parentage 003Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com DECLARATION IN SUPPORT OF ESTABLISHING PARENTAGE , PAGE 3002 Section I. Declaration (Continued) : 5.003 Is any person other than the birth mother named on the child222s birth certificate? [ ] Yes [ ] No If yes, provide the individual222s name, address, and gender: 6. 003 Has any person completed a voluntary acknowledgment of parentage for this child [ ] Yes [ ] No (If yes, attach document.) that has been rescinded? If yes, provide the individual222s name, address, and gender: Section II. To Be Completed by the Petitioner (complete either 1 or 2, as appropriate): [ ]003 1. I assert that the respondent, , is the parent of the child. The following facts support my allegations of parentage: (If an explanation is needed, use section IV.) a. I lived with the respondent. [ ] Yes Dates to Location: [ ] No [ ] Not applicable b. I told the respondent that he/she is the parent of the child. [ ] Yes [ ] No [ ] Not applicable c. The respondent admitted being the parent of the child. [ ] Yes [ ] No d. The respondent communicated about the pregnancy and/or about [ ] Yes [ ] No [ ] Copies of communications attached the child. e. The respondent was present at the birth of the child. [ ] Yes [ ] No f. The respondent visited the child at the hospital following birth. [ ] Yes [ ] No g. The respondent offered to pay abortion expenses. [ ] Yes [ ] No h. The respondent offered to pay/paid medical expenses. [ ] Yes [ ] No i. The respondent offered to pay/paid birth related expenses. [ ] Yes [ ] No j. The respondent claimed the child on a tax return. [ ] Yes [ ] No [ ] Don222t k now k. The respondent provided food, clothing, gifts, or financial support [ ] Yes [ ] No for the child. l. The respondent lived with the child. [ ] Yes [ ] No m. The respondent visited the child. [ ] Yes [ ] No n. The child resembles the respondent. [ ] Photo attached [ ] Yes [ ] No Declaration in Support of Establishing Parentage 003Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com DECLARATION IN SUPPORT OF ESTABLISHING PARENTAGE , PAGE 4002 Section II. T o B e C ompleted by t he P etitioner (Continued) : [ ] 2.003 I, , assert that I am the parent of the child: The following facts support my belief and statements that I am the parent of the child: (If an explanation is needed, use section IV.) a. I lived with the respondent. [ ] Yes [ ] No Dates to Location b. The respondent told me that I am the parent of the child. [ ] Yes [ ] No c. I was present at the birth of the child. [ ] Yes [ ] No d. I visited the child at the hospital following birth. [ ] Yes [ ] No e. I offered to pay abortion expenses. [ ] Yes [ ] No f. I offered to pay/paid medical expenses. [ ] Yes [ ] No g. I offered to pay/paid birth related expenses. [ ] Yes [ ] No h. I claimed the child on a tax return. [ ] Yes [ ] No i. I provided food, clothing, gifts, or financial support for the child. [ ] Yes [ ] No j. I lived with the child. [ ] Yes [ ] No k. I visited the child. [ ] Yes [ ] No l. The child resembles me. [ ] Photo attached [ ] Yes [ ] No Section III. To Be Completed by the Birth Mother Only: 1.003 I had sexual intercourse with a man (other than the person I am naming as the respondent) during the 30 days before or 30 days after the child was conceived. [ ] Yes [ ] No (If yes, complete the following.) a.003 The name(s) and address(es) of the other man/men: b.003 The other man/men is/are biologically related to the person I am naming as the respondent.002 [ ] Yes [ ] No. (If yes, explain the biological relationship in the space below, e.g., brother, cousin, uncle.)002 c.003 I do not believe the other man/men is/are the child222s biological parent because: Declaration in Support of Establishing Parentage 003Page 4 of 5 American LegalNet, Inc. www.FormsWorkFlow.com DECLARATION IN SUPPORT OF ESTABLISHING PARENTAGE PAGE 5002 Section IV . Other P ertinent I nformation : (Include detailed information for section I, section II, or section III above.) [ ] Continued on attached sheet(s), incorporated by reference. Section V. Declaration: Under penalty of perjury, all information and facts stated in this Declaration are true to the best of my knowledge and belief. I agree to submit myself and, if I am the custodian, the child to genetic testing as may be necessary to establis