Court File No. STATE OF NORTH CAROLINA IV-D Case No. County In The General Court Of Justice District Court DivisionName And Address Of Plaintiff Plaintiffs Social Security No. MOTION AND NOTICE OF HEARING VERSUS Name And Address Of Defendant TO RESCIND AFFIDAVIT OF PARENTAGE Defendants Social Security No. G.S. 110-132 MOTION I hereby request the Court rescind the Affidavit Of Parentage that I signed. 1. A copy of the Affidavit Of Parentage is attached to this Motion. 2. This motion was filed within sixty (60) days of the date that I signed the Affidavit Of Parentage. 3. To the best of my knowledge, a court order regarding the paternity of or child support for the child(ren) named in the attached Affidavit Of Parentage has not been entered. Therefore, the undersigned requests that the District Court order the rescission and include a specific finding that the motion to rescind was filed with the Clerk of Superior Court within sixty (60) days of signing the attached Affidavit Of Parentage. Name And Address Of Party Making Motion (Type Or Print) Date Signature Of Party Making Motion Plaintiff Defendant Attorney NOTICE OF HEARING NOTICE TO: (Name of party(ies) to be served) You are notified to appear at the date, time and location shown below to answer the above Motion And Notice Of Hearing To Rescind Affidavit Of Parentage. Date of Hearing Time Of Hearing Location of Hearing AM PM Date Of Notice Signature Deputy CSC Assistant CSC Clerk of Superior Court INSTRUCTIONS TO THE MOVING PARTY: A copy of the Affidavit Of Parentage that you signed must be attached to this Motion. This Motion must be filed within sixty (60) days from the date you signed the Affidavit Of Parentage or before a court order for paternity or child support is entered with respect to the child(ren) named in the Affidavit Of Parentage. After you have completed this form, file it with the Clerk of Superior Court and ask the Clerk to schedule a hearing. Then serve the other party who signed the Affidavit Of Parentage (and the state or local child support enforcement agency if the agency is involved with the paternity or support of the child(ren) named in the Affidavit Of Parentage) through the Sheriffs office or by certified mail. If you are serving the Motion by certified mail, prepare and file proper affidavit of service. You will need to come to court for a hearing on the date and time specified above. AOC-CV-916M, Rev. 3/03 (Over) 2003 Administrative Office of the Courts >>>> 2 RETURN OF SERVICE I certify that this Motion and Notice was received and served as follows: PARTY Date Served Time Served Name Of Party AM PM By delivering to the party named above a copy of this Motion and Notice. By leaving a copy of this Motion and Notice at the dwelling house or usual place of abode of the party named above with a person of suitable age and discretion then residing therein.Name And Address Of Person With Whom Copies Left Other manner of service: (specify) The party WAS NOT served for the following reason: IV-D AGENCYDate Served Time Served Name Of IV-D Agency AM PM (County IV-D Agency) By personally delivering a copy of this Motion and Notice to the county manager, a county commissioner or the clerk to the board of county commissioners named below. Name, Title And Address Of Person Served (State IV-D Agency) By personally delivering a copy of this Motion and Notice to the designated process agent for the Department of Health and Human Services named below. Name, Title And Address Of Person Served Service Fee Paid Signature Of Deputy Sheriff Making Return$ Date Received Name Of Sheriff (Type Or Print)Date Of Return County Of Sheriff AOC-CV-916M, Side Two, Rev. 3/03 2003 Administrative Office of the Courts