Superior Court of Washington County of In re Parentage: Petitioner, and Respondent and No. Declaration of Mother (Parentage) (DCLR) Respondent. I. Declaration of Mother ___________________________________ [Name] Declares: 1.1 I am the mother of the child ___________________________ [Name] born on _________ [Date]. 1.2 [] Within the period from ______________ [Date] to ______________ [Date] this child was conceived. I had sexual intercourse only with ____________________________ [Name] within this time period and he must be the father. [] Within the period from ______________ [Date] to ______________ [Date], this child was conceived. I had sexual intercourse with: ________________________________ _______________________________________________________________ [Names]. Within this period, this child was conceived and one of these men must be the father. [] Within this period, sexual intercourse with ______________________________ [Name] occurred in the state of Washington which may have resulted in the conception of this child. [] [] [] Does not apply. Under RCW 26.26.116, the presumed father of the child is _________________ [Name]. ______________________ [Name of presumed father] and the mother did not cohabit or engage in sexual intercourse with each other during the probable time of conception, and he never openly treated the child as his own. 1.3 Declaration of Mother (DCLR) - Page 1 of 3 WPF PS 01.0150 (6/2006) – Chapter 26.26 RCW American LegalNet, Inc. www.FormsWorkflow.com 1.4 Other: II. Military Service [] To the best of my knowledge and belief _____________________________ [Name] is not a service member or a dependent of a service member. To the best of my knowledge and belief ______________________________ [Name] [] [] [] [] [] is on active duty in the U.S. armed forces (excluding National Guard and reserves); is on active duty and is a National Guard member or a Reservist residing in Washington. is not on active duty in the U.S. armed forces (excluding National Guard and reserves); is not on active duty and is a National Guard member or a Reservist residing in Washington. other: To the best of my knowledge and belief ___________________________ [Name] [] [] [] is a dependent of a resident of Washington who is on active duty and is a National Guard member or a Reservist; is not a dependent of a resident of Washington who is on active duty and is a National Guard member or a Reservist; other: III. Statement of Non-Representation I have been informed and understand that the attorney for the state of Washington (Attorney General/Prosecutor) does not represent me in this matter. I understand that I have the right to retain my own attorney at any time. IV. Uniform Child Custody Jurisdiction and Enforcement Act Statement During the last five years, the child has lived: [] [] in no place other than the state of Washington and with no person other than the declarant or a named party. in the following places with the following persons (list each place the child lived, including the state of Washington, the dates the child lived there and the names of the persons with whom the child lived. The present addresses of those persons must be listed in the required Confidential Information Form.): Declaration of Mother (DCLR) - Page 2 of 3 WPF PS 01.0150 (6/2006) – Chapter 26.26 RCW American LegalNet, Inc. www.FormsWorkflow.com Claims to custody or visitation. [] [] I do not know of any person other than a named party who has physical custody of, or claims to have custody or visitation rights to the child. The following persons have physical custody of, or claim to have custody or visitation rights to the child (list their names and the child(ren) concerned below and list their present addresses in the Confidential Information Form. Do not list the responding party.): Involvement in any other proceeding concerning the child: [] [] I have not been involved in any other proceeding regarding the child. I have been involved in the following proceedings regarding the child (list the court, the case number, and the date of the judgment or order): Other legal proceedings concerning the child: [] [] I do not know of any other legal proceedings concerning the child. I know of the following legal proceedings which concern the child (list the child concerned, the court, case number and the kind of proceeding): [] Other: I declare under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct. Signed at ________________________, [City] ___________ [State] on ___________________ [Date]. Signature of Mother Print or Type Name Declaration of Mother (DCLR) - Page 3 of 3 WPF PS 01.0150 (6/2006) – Chapter 26.26 RCW American LegalNet, Inc. www.FormsWorkflow.com