Fillable Printable Florida Health Acknowledgment of Paternity

Florida Health Acknowledgment of Paternity

ACKNOWLEDGMENT OF PATERNITY

TYPE OR PRINT IN BLUE OR BLACK INK

THIS FORM MUST BE SIGNED BY BOTH MOTHER AND FATHER IN THE PRESENCE OF A NOTARY PUBLIC OR BEFORE TWO WITNESSES.

IMPORTANT - Read Information and Instructions on the reverse side of this form and acknowledge your understanding by signing at the bottom

of the reverse side of this form as well as below under "Acknowledgment By Natural Parents".

INFORMATION TAKEN FROM ORIGINAL BIRTH CERTIFICATE

Child's SSN: ___________________________________ State File/Birth Number: _____________________________

(If Known)

Full Name of Child: _____________________________________________________________________________ Sex: _________________

(First) (Middle) (Last)

Child's Place of Birth: ____________________________________________________________ Child's Date of Birth: ___________________

(City) (County) (State) (Zip)

(Month/Day/Year)

Mother's Full Mother's Place of Birth

Maiden Name: ______________________________________________________________ __________________________________________

(First) (Middle) (Last)

(State or Country)

Mother's Social Security Number: ______________________________________ Mother's Date of Birth: _____________________________

(Month/Day/Year)

INFORMATION FOR NEW BIRTH CERTIFICATE

Full Name of Child for New Birth Certificate: ________________________________________________________________________________

(See Reverse Side of form) (First) (Middle) (Last) (Suffix)

Natural Father's

Full Name: __________________________________________________________________________________________________________

(First) (Middle) (Last)

Date of Birth

of Father: _______________________________________________

Father's Social Security Number: ______________________________

(Month/Day/Year)

Place of Birth

Father's Race: _______________________ of Father: _____________________________________________________________________

(City) (County) (State)

Mailing Address of Residence Address

Father if Different: __________________________________________ Of Father: ___________________________________________

(Street/Box No./Route) (Street/Box No./Route)

____________________________________________________ ______________________________________________________

(City) (County) (State) (Zip)

Current Mailing Address of Mother

_____________________________________________________________________________________________________________________

(Street/Box No./Route) (City) (State) (Zip)

NOTE: If married after child's birth and now request amendment of marital status on birth record, send certified copy of marriage record with this

form. If married in Florida and you require a certified copy, fill-in data below and send $5.00. A certified copy will be sent to you upon completion,

if married in Florida: Date: _______________________________________ County issuing license: ____________________________________

ACKNOWLEDGMENT BY NATURAL PARENTS

Under penalties of perjury, WE HEREBY DECLARE that we have read the foregoing Acknowledgement of Paternity and that the facts stated in it are

true, that is, that the mother was unwed at the time of birth, that no other man is listed on the birth record as father, that we are the natural parents of the

child named above and that we fully understand our responsibilities and rights printed on the reverse side of this form, DH 432, (11/04). WE FURTHER

DECLARE that no court action establishing paternity has occurred or is in process. We understand that a person who knowingly makes a false

declaration pursuant to s. 92.525(2) or 382.026(1), Florida Statutes is guilty of perjury by false written declaration, a felony of the third degree,

punishable as provided in s. 775.082, s. 775.083, or s. 775.084.

IF NOTARIZED

Sworn to and subscribed before me this ____Day of _________, 20___, by Sworn to and subscribed before me this ____Day of _________, 20___, by

______________________________________________________________ ______________________________________________________________

(Signature of Natural Father) (Signature of Natural Mother)

_______________________________________________ _______________________________________________

(Printed Name of Natural Father) (Printed Name of Natural Mother)

______________________________________________________________ ______________________________________________________________

(Notary Signature) (Notary Signature)

_____________________________________________________________ _____________________________________________________________

(Printed Name/Notary Stamp) (Printed Name/Notary Stamp)

Personally known ______ OR Produced Identification __________ Personally known ______ OR Produced Identification ___________

Type of Identification Produced: _______________________ Type of Identification Produced: _______________________

OR, IF NOT NOTARIZED ABOVE, WITNESSED BELOW

Printed Name of Natural Father Printed Name of the Natural Mother

Signature of Natural Father/Date Signed Signature of Natural Mother/Date Signed

Witness: _____________________________ ____________________________________ Witness: _____________________________ ___________________________________

(Printed Name) (Signature) (Printed Name) (Signature)

Witness: _____________________________ ____________________________________ Witness: _____________________________ ___________________________________

(Printed Name) (Signature) (Printed Name) (Signature)

DH Form432, (Rev. 2/06 - Obsoletes Previous Editions, Which may not be used)

Please Turn Sheet Over

DH Form 432, (Rev. 2/06 - Obsoletes Previous Editions, Which may not be used)

***WHAT YOU AS A PARENT MUST KNOW BEFORE SIGNING THIS ACKNOWLEDGMENT OF PATERNITY***

BENEFITS FOR THE CHILD AND PARENTS

* Identity and Security · *Support from the child's father and mother * Access to the father's medical benefits

* Access to the father's medical history information * Access to survivor's benefits and rights of inheritance

Upon receipt of this properly notarized or witnessed form, the Office of Vital Statistics shall prepare and file a new birth record

reflecting the information as shown under section entitled "INFORMATION FOR NEW BIRTH CERTIFICATE". The original

birth record and this "ACKNOWLEDGMENT OF PATERNITY" will be placed under seal only to be opened and released

pursuant to an order from a court of competent jurisdiction. Since documentation supporting the amendment may be required by

the Social Security Administration, or other agencies, we suggest you make a copy of this form for your records prior to

submission. NOTE: If signatures of mother and father have been witnessed, please provide picture identification for each

parent as picture identification must be provided for us to issue certification of the amended record to either of the parents.

Acceptable forms are a driver's license, passport, state identification card or military identification card.

RIGHTS, RESPONSIBILITIES AND DUTIES: When both parents sign this ACKNOWLEDGMENT OF PATERNITY they

swear they are the natural parents of this child. After signing, either parent has the right to cancel the effect of the acknowledgment

within 60 days unless there has been a court hearing regarding that parent and the child. If there is no court hearing within 60 days

of when the acknowledgment is signed, paternity is legally established under the laws of Florida. Once the

ACKNOWLEDGMENT OF PATERNITY is signed by both parents, the name of the father is placed on the child's birth

certificate. Even if the ACKNOWLEDGMENT OF PATERNITY is cancelled within 60 days, the birth certificate can only be

changed and the father's name removed by a court order. Contact this office if you wish to file a rescission.

After paternity is legally established, paternity can only be challenged by proving in court that your signature on the

ACKNOWLEDGMENT OF PATERNITY was obtained through fraud, under duress, or that there was a material mistake in fact.

The court will decide whether your name can be removed. Do not sign the ACKNOWLEDGMENT OF PATERNITY if you are

not certain you are the child's father.

WHAT ARE YOU AGREEING TO? If you are the mother, you are agreeing that the person signing as the child's father is, in

fact, the biological father of your child. If you are the father, you are agreeing that you are the biological father of the child and

you and the mother will be responsible for the child's financial and medical support until he or she is an adult. This usually means

until the child is eighteen years old.

CAN I SIGN IF I AM LESS THAN 18 YEARS OLD? According to the law, a minor can sign the acknowledgment. However,

minors are encouraged to obtain the consent of their legal guardian before signing the acknowledgment. An understanding of the

rights and responsibilities associated with establishing paternity by acknowledgment is important before completing the form.

CONSEQUENCES: By signing this ACKNOWLEDGMENT OF PATERNITY you declare that the mother was unwed at the

time of her child's birth and that you are the child's parents, and that you are undertaking responsibility for this child as provided

by law. Designated health or Child Support staff are required to explain and clarify the ACKNOWLEDGMENT OF PATERNITY

and paternity establishment to both mother and father, to inform you of your rights and give you the opportunity to voluntarily

acknowledge paternity. Original signatures are required. If you have any questions, now is the time to ask. If you do not

understand it, do not sign it. After you both sign and submit the ACKNOWLEDGMENT OF PATERNITY a birth certificate

listing both parents will be placed on file.

ALTERNATIVE TO SIGNING: Under Florida law, if both parents do not sign this ACKNOWLEDGMENT OF PATERNITY,

paternity may be established by the court. A paternity action may be filed by the mother, the natural father, the child and/or the

state on behalf of the mother, the father, or the child. If a court action is filed, either parent may be ordered to pay costs, including

the cost of genetic testing. All costs, including genetic tests, will be billed to the man found to be the legal father. If you want to

file a court action to establish paternity and you need help, contact the local Department of Revenue Child Support Enforcement

Office or a private attorney.

INFORMATION FOR NEW CERTIFICATE: If the child is under the age of one, a change to the child's given name may be

requested by entering the name as you wish it shown on the new birth certificate. If the child is more than one year, a change other

than a misspelling, omission, or a correction that is accompanied by supporting documentary evidence, can only be made upon

receipt of an order from a court of competent jurisdiction. A change to a child's surname to the mother's maiden name, father's

surname or a combination of both can be made regardless of the child's age by entering the name as you wish it to appear on the

new birth certificate. The new birth record will show child's name as well as father's name and personal identifying information

regarding him as reflected on this form. Therefore, be sure to list the information as you wish it reflected on the new record. If

only an initial is shown for a given name, a name omitted, wrong surname, etc. the new record can only be amended in regard to

the child's name by a court of competent jurisdiction. Evidence of the father's true facts of birth in the form of a birth certificate

or other documentation may be required to correct any information provided to us in error.

FEE/CERTIFICATION OF NEW RECORD: An amendment-processing fee of $20.00 is

required which includes the issuance

of one certification of the new birth record. Picture identification must be provided for us to issue certification of the amended

record. Acceptable forms are a driver's license, passport, state identification card or military identification card.

DH Form 429, Application for Amendment to Florida Birth Record is available for remittance. If you need assistance, please e-

mail our office at [email protected]

MAIL TO: STATE OFFICE OF VITAL STATISTICS, ATTN: PATERNITY UNIT, P. O. BOX 210, JACKSONVILLE, FL 32231-0042.

I HAVE READ [OR HAVE HAD READ TO ME] AND UNDERSTAND THIS DOCUMENT:

Signature of Natural Father: _________________________________

Date Signed: _____________________________________________

Signature of Natural Mother: ________________________________

Date Signed: _____________________________________________

DH Form 432, (Rev. 2/06 - Obsoletes Previous Editions Which may not be used)