*03PA210E-001* OKLAHOMA DEPARTMENT OF HUMAN SERVICES Denial of Paternity This is a legal document. Type or print in ink by pressing hard. No cross outs, correction fluid, or alterations allowed. Complete this form only when the child is born during the marriage or within 300 days after the marriage is terminated and the presumed father is NOT the natural father. The person that needs to sign this Denial of Paternity form is the presumed father, as described on the back of this form. The presumed father agrees that he is not the natural father of the child. The child must be less than two years old. Completion of this Denial of Paternity by the presumed father AND Form 03PA209E, Acknowledgment of Paternity, by the natural father, allows the child's birth certificate to include the natural father's name. Section l. Child's information as it now appears on birth certificate Child's first name Middle Date of birth (mo/day/yr) Last Sex, check one Female Male County State City of birth Last Maiden name Section II. Mother's information Mother's first name Middle Section III. Presumed father's information Presumed father's first name Social Security number Present street address Middle Date of birth (mo/day/yr) City Last Suffix Area code Daytime phone number State Zip code Section IV. Presumed father's signature By signing below, I declare under penalty of perjury that I have read and understand this Denial of Paternity. I declare the information in this Denial is true and: 1. I am the presumed father of the child identified on this form. 2. I am NOT the natural father of the child identified on this form. 3. I have not acknowledged paternity of this child. 4. No court has determined that I am the father of this child. 5. I understand the name of the natural father will be placed on the child's birth certificate. Presumed father 's signature Signature of witness Date and place Printed name of witness You have the right to withdraw your denial within 60 days after the effective date of the Acknowledgment of Paternity. You must file a signed Form 03PA213E, Rescission of Denial of Paternity, with the Oklahoma State Department of Health (OSDH), Division of Vital Records. To obtain Form 03PA213E, call 405-522-2273 in the Oklahoma City calling area, 918-295-3500 in the Tulsa calling area, 1-800-522-2922 toll free, or contact your closest child support office or OSDH Division of Vital Records. Distribution of copies: white to OSDH Division of Vital Records, yellow to OKDHS Oklahoma Child Support Services (OCSS), pink to Mother, gold to Presumed Father. Issued 11-1-2006 03PA210E (CSED-209-D) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 03PA210E (CSED-209-D) Denial of Paternity Information for completing this Denial of Paternity Please read these instructions and the entire form before you sign it. A man is presumed to be the father of a child if: 1. he and the mother of the child are married to each other and child is born during the marriage; 2. he and the mother of the child were married to each other and the child is born within 300 days after the marriage is terminated by death, annulment, declaration of invalidity, dissolution of marriage, or after a decree of separation; 3. before the birth of the child, he and the mother of the child married each other in apparent compliance with law, even if the attempted marriage is or could be declared invalid, and the child is born during the invalid marriage or within 300 days after its termination by death, annulment, declaration of invalidity, a decree of separation, or dissolution of marriage; 4. after the birth of the child, he and the mother of the child married each other in apparent compliance with law, whether or not the marriage is or could be declared invalid, and he voluntarily asserted his paternity of the child, and: • • • the assertion is in a record with the Oklahoma State Department of Health (OSDH), Division of Vital Records, or OKDHS; he agreed to be and is named as the child's father on the child's birth certificate; or he promised in a record to support the child as his own; or 5. for the first two years of the child's life, he resided in the same household with the child and openly held out the child as his own. Only a presumed father may sign a Denial of Paternity. The denial is valid only if: 1. an Acknowledgment of Paternity is signed by another man and is filed with the OSDH Division of Vital Records; 2. the denial is in writing and is signed under penalty of perjury; 3. the presumed father has not previously: • acknowledged his paternity, unless the previous acknowledgment has been rescinded or successfully challenged; or • been determined to be the father of the child by a court; and 4. the denial is signed before the child is two years old. If the presumed father is unwilling or unable to sign this denial, the presumed father will be the legal father of the child and will be named as the father on the birth certificate. When the presumed father will not sign, the only way to remove the presumed father's name and add the natural father's name on the child's birth certificate is by court order. Instructions for completing this Denial of Paternity After this form has been completed, signed and witnessed, give the pink copy to the mother and the gold copy to the presumed father. Do not separate the other pages of the Denial. Mail the white and yellow copies of this Denial and Form 03PA209E, Acknowledgment of Paternity, to: Oklahoma State Department of Health Division of Vital Records P. O. Box 53551 Oklahoma City, OK 73152 Disclosure of your Social Security number, and the Social Security number of your child, is required by federal law. [42 USC §666] OCSS will use these Social Security numbers only for the purpose of establishing paternity and, if requested or required to do so, establishing and enforcing support for you and your family. Page 2 of 2 Issued 11-1-2006 American LegalNet, Inc. www.FormsWorkFlow.com