Form 03PA211E Page 1 of 2 3/1/2018Rescission of Acknowledgment of Paternity This is a legal document. Type or print in ink by pressing hard. No cross outs, correction fluid, or alterations are allowed. This form is used to withdraw your sworn statement about paternity of a child. This form must be completed and filed with the Oklahoma State Department of Health (OSDH), Division of Vital Records, within 60 days from the date of the last signature on Form 03PA209E, Acknowledgment of Paternity. When this form is properly completed and filed with OSDH Division of Vital Records, the man named as the biological father on Form 03PA209E, Acknowledgment of Paternity, will no longer be the legal father and his name will be removed from the birth certificate. This form must be signed by the rescinding parent (mother or father) in the presence of a witness. The witness may not be related to you. Child's Information as it Now Appears on Birth Certificate Child's first name Middle Last Male FemaleSex: Date of birth City of birth County State Parent's Information as it Appears on the Acknowledgment of Paternity Mother's first name Middle Last Maiden name Father's first name Middle Last Suffix Spouse as it appears on the Denial of ParentageWas mother married at time of conception or birth? Yes No If yes, spouse's name: Rescinding Parent's (Mother's or Father's) Information Parent's first name Middle Last Suffix Social Security number Date of birth Daytime phone number Current street address City State ZIP code SignatureBy signing below, I declare under penalty of perjury that I have read and understand this Rescission of Acknowledgment of Paternity. I declare the information in this Rescission is true. I understand that by completing this form and filing it with the OSDH Division of Vital Records, I am withdrawing the acknowledgment of paternity for the above-named child created by a previously completed Form 03PA209E, Acknowledgment of Paternity, on or about the date of . Rescinding parent's signature Date and place Witness signature Printed name of witness American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 3/1/2018 Form 03PA211E Instructions for Completing This Rescission of Acknowledgment of PaternityPlease read these instructions and the entire form before you sign it. This form must be completed and filed with the Oklahoma State Department of Health (OSDH), Division of Vital Records, within 60 days from the date of the last signature on Form 03PA209E, Acknowledgment of Paternity. This form may be completed by either person (mother or father) who originally signed the Acknowledgment of Paternity. After this form has been completed, signed and witnessed, the mother and spouse should keep a copy and send the original and one copy to the following address. If there are multi-colored copies, give the pink copy to the mother and the gold copy to the acknowledging father and the green copy to the spouse of the biological mother as listed on Form 03PA210E, Denial of Parentage, if a Denial of Parentage has been signed. Do not separate the other pages of the Rescission. Mail the white and yellow copies of this Rescission of Acknowledgment of Paternity to the following address: 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 247666]. CSS 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. American LegalNet, Inc. www.FormsWorkFlow.com