Fillable Printable Paternity Affidavit Form Sample
Fillable Printable Paternity Affidavit Form Sample
Paternity Affidavit Form Sample
AFFIDAVIT IN SUPPORT OF ESTABLISHING PATERNITY
Petitioner: Name (first, middle, last) IV-D Case:
Social Security Number
Respondent: Name (first, middle, last)
Social Security Number
Non-IV-D Case:
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
Responding IV-D Case No.
Responding Tribunal No.
TANF
IV-E Foster Care
Medicaid Only
Former Assistance
Never Assistance
File Stamp
Initiating IV-D Case No.
Initiating Tribunal No.
A Separate Affidavit Is Required for Each Child Needing Paternity Established.
SECTION I
I, , on oath, under penalty of perjury depose and allege:
Name (first, middle, last)
1. I am the [ ] natural mother of the child named below:
[ ] natural father
[ ] other; explain in Section IV
Child’s Full Legal Name
(first, middle, last) Child’s Date of Birth
(Month, Day, Year)
Place of Birth (City, County, State)
Date Mother Got Pregnant
(Month, Year)
Full Term Pregnancy
[ ] Yes
[ ] No
(If No, explain)
Where Mother Got Pregnant (City, County, State)
Mother’s Maiden Name (first, middle, last)
2. The child was conceived as a result of sexual intercourse between
and me during the time stated above.
Name (first, middle, last)
3. a. A man is named as the father on the child’s birth certificate.
If Yes, the man’s name and address are:
[ ] Yes (Attach certified copy) [ ] No
b. A man was married to the natural mother, and the child’s birth
occurred within a year of the end of the marriage.
If Yes, the man’s name and address are:
[ ] Yes [ ] No
Date marriage ended
(Month, Day, Year)
c.
A man signed an acknowledgment of paternity before an
acknowledgment became a legal finding of paternity under State
law.
[ ] Yes (Attach certified copy) [ ] No
d. A man acted as and presented himself to be the child’s father.
If Yes, the man’s name and address are:
[ ] Yes [ ] No
e. Genetic tests were completed to determine the biological father of the
child. If Yes, attach results.
[ ] Yes [ ] No
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CSF 11 0112 (Rev. 02/10/09)
AFFIDAVIT IN SUPPORT OF ESTABLISHING PATERNITY, PAGE 2 Initiating IV-D Case No.
SECTION II (TO BE COMPLETED BY MOTHER ONLY)
1.
2.
3.
I had sexual intercourse with another man (other than the man I am naming as the child’s natural father) during
the time 30 days before or 30 days after the child was conceived. [ ] Yes [ ] No
(If Yes, complete the following).
a. The name(s) and address(es) of the other man/men:
b. The other man/men are biologically related to the man I am naming as the child’s natural father.
[ ] Yes [ ] No. If Yes, explain the biological relationship
(e.g., brother, cousin, uncle, etc.)
c. I do not believe the other man/men is/are the father because:
I was married at the time of this child’s birth. [ ] Yes [ ] No. (If Yes, complete the following)
a. Husband’s name
(first, middle, last) and last known address:
b. Explain why the husband is not the father of this child and attach all appropriate documents, including
divorce decree, genetic test results and prior findings of non-paternity, if any:
is the father of this child. The following facts support my allegations of paternity:
Name (first, middle, last)
a. We lived together. [ ] Yes [ ] No
Dates:
Location
To
b. I have told welfare officials that he is the father of
this child. [ ] Yes [ ] No
c. I told him that he was the father of the child. [ ] Yes [ ] No
d. He is named as the father on the birth certificate. [ ] Yes [ ] No
[ ] Certified Copy Attached
e.
He signed an acknowledgment of paternity before
an acknowledgment became a legal finding of
paternity under State law.
[ ] Yes [ ] No
[ ] Certified Copy Attached
f. He admitted being the father of the child. [ ] Yes [ ] No
g. He sent cards/letters regarding the pregnancy and/or
about the child.
[ ] Yes [ ] No
[ ] Copies Attached
h. He was present at the birth of the child. [ ] Yes [ ] No
i. He visited the child at the hospital following birth. [ ] Yes [ ] No
j. He offered to pay abortion expenses. [ ] Yes [ ] No
k. He offered to pay medical expenses. [ ] Yes [ ] No
l. He paid for birth related expenses. [ ] Yes [ ] No
m. He claimed the child on tax returns. [ ] Yes [ ] No [ ] Don’t Know
n. He has provided food, clothing, gifts or financial
support for the child. [ ] Yes [ ] No
If Yes, explain in Section IV
o. He lived with the child. [ ] Yes [ ] No
If Yes, explain in Section IV
p. He visited the child. [ ] Yes [ ] No
If Yes, explain in Section IV
q. The child resembles him. [ ] Photo attached [ ] Yes [ ] No
If Yes, explain in Section IV
r. There are witnesses to my relationship with him. [ ] Yes [ ] No
(If Yes, list names and addresses and briefly describe relevant facts known by each under Section IV)
Page 2 of 3 - AFFIDAVIT IN SUPPORT OF ESTABLISHING PATERNITY
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AFFIDAVIT IN SUPPORT OF ESTABLISHING PATERNITY, PAGE 3 Initiating IV-D Case No.
SECTION III (TO BE COMPLETED BY FATHER ONLY)
The following facts support my belief and statements that I am the father of this child:
a. The mother and I lived together. [ ] Yes [ ] No
Dates: To
Location:
b. The mother told me that I am the father of the child. [ ] Yes [ ] No
c. I am named as the father on the birth certificate. [ ] Yes [ ] No
[ ] Certified Copy Attached
d.
I signed an acknowledgment of paternity before an
acknowledgment became a legal finding of
paternity under State law.
[ ] Yes [ ] No
[ ] Certified Copy Attached
e. I was present at the birth of the child. [ ] Yes [ ] No
f. I visited the child at the hospital following birth. [ ] Yes [ ] No
g. I offered to pay abortion expenses. [ ] Yes [ ] No
h. I offered to pay medical expenses. [ ] Yes [ ] No
i. I paid for birth related expenses. [ ] Yes [ ] No
j. I claimed the child on tax returns. [ ] Yes [ ] No
k. I have provided food, clothing, gifts or financial
support for the child. [ ] Yes [ ] No
If Yes, explain in Section IV
l. I lived with the child. [ ] Yes [ ] No
If Yes, explain in Section IV
m. I visited the child. [ ] Yes [ ] No
If Yes, explain in Section IV
n. The child resembles me. [ ] Photo attached [ ] Yes [ ] No
If Yes, explain in Section IV
o. There are witnesses to my relationship with the
child’s mother.
[ ] Yes [ ] No
(If Yes, list names and addresses and briefly describe relevant facts known by each under Section IV)
SECTION IV – OTHER PERTINENT INFORMATION (including detailed explanations for “Yes” responses in
Section II or Section III above)
[ ]
Continued On Attached Sheet(s), incorporated by reference
All of the information and facts contained in this AFFIDAVIT IN SUPPORT OF ESTABLISHING PATERNITY are
true and correct to my best knowledge and belief. I agree to submit myself and, if I am the custodian, my child to
genetic testing as may be necessary to establish paternity.
Date Signature
Sworn to and Signed before me this Date, County and State
Notary Public/Official and Title
Commission Expires
Page 3 of 3 - AFFIDAVIT IN SUPPORT OF ESTABLISHING PATERNITY
CSF 11 0112 (Rev. 02/10/09)
INSTRUCTIONS FOR AFFIDAVIT IN SUPPORT OF ESTABLISHING PATERNITY
PURPOSE OF THE FORM:
This affidavit supplements the Uniform Support Petition to summarize evidence to establish paternity. A separate
Affidavit in Support of Establishing Paternity is required for each child needing paternity establishment. This is
necessary since the circumstances surrounding conception and birth will differ unless the children are twins. Reminder:
A putative father may petition for paternity establishment under UIFSA. All appropriate information for the Affidavit in
Support of Establishing Paternity must be completed or furnished by the parent, properly signed by the parent, and
notarized as required. A separate Affidavit is required for each allegation of paternity.
Italicized text that appears within a “box” refers to policy or provides additional information.
HEADING/CAPTION: [To be completed by the Child Support (IV-D) Worker]
# Identify the petitioner and respondent name (first, middle, last) and Social Security Number in the appropriate
spaces.
# Check the appropriate space to identify the type of case: TANF; IV-E Foster Care, Medicaid only; former
assistance, never assistance, or Non-IV-D.
TANF means the obligee's family receives IV-A cash payments. A Medicaid only case is a case where the obligee's
family receives Medicaid but does not receive TANF (IV-A cash payments).
# In the appropriate spaces, if applicable and if known, enter the Responding jurisdiction’s FIPS code, State, IV-D
case number, and Tribunal number.
Under “IV-D case number”, enter the number/identifier identical to the one submitted on the Federal Case Registry,
which is a left-justified 15-character alphanumeric field, allowing all characters except asterisk and backslash, and
with all characters in uppercase. Under "tribunal number", you may enter the docket number, cause number, or any
other appropriate reference number that the respondent State may use to identify the case, if known. The Responding
jurisdiction is the jurisdiction that is working the case at the request of the initiating jurisdiction..
# In the appropriate spaces, enter the Initiating jurisdiction’s IV-D case number and tribunal number.
Under “IV-D case number”, enter the number/identifier identical to the one submitted on the Federal Case Registry,
which is a left-justified 15-character alphanumeric field, allowing all characters except asterisk and backslash, and
with all characters in uppercase. Under "tribunal number", you may enter the docket number, cause number, or any
other appropriate reference number which the initiating tribunal or agency has assigned to the case. The initiating
jurisdiction is the jurisdiction that referred the case to the responding jurisdiction for services.
SECTION I: (Information to be completed or furnished by parent of the child)
Enter the full name (First, Middle, Last) of the parent or other individual completing the affidavit.
Item 1: Check whether you (the parent) are the natural mother or natural father of the child or, if other, explain your
relationship in Section IV.
• Enter the "Child's Full Legal Name", "Child's Date of Birth", and "Place of Birth".
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CSF 11 0112 (Rev. 02/10/09)
• "Date Mother Got Pregnant" - Enter the period of time when you believe the mother became pregnant (e.g., 4/89
or from 4/89 to 5/89). Be sure to include both the month (or months) and the year when providing date(s). Be as
specific as possible.
• "Full Term Pregnancy" - Check "Yes" or "No" to indicate whether or not the pregnancy lasted nine months. If
no, explain (e.g., 6 months--child born premature).
• "Where Mother Got Pregnant" - List the City, County, and State.
• “Mother’s Maiden Name” - Enter the mother’s maiden name, if known.
Item 2: Enter the name of the child's other parent in the blank. This is the person with whom you (the parent completing
the affidavit) had sexual intercourse which resulted in the child's conception.
Item 3: The information in item 3 is intended to identify whether there is a presumed or legal father under State law.
State laws differ on whether and how a presumption of paternity is created.
Item 3a: Check "Yes" or "No" to indicate whether or not a man is named as the child's father on the child's birth
certificate. If "Yes", attach a certified copy of the birth certificate and provide the man's name and address.
The man may be the same man who is named as the father of the child in this affidavit, or he may be a different man.
NOTE: Some responding States may only need a regular copy, rather than a certified copy of this document.
Item 3b: Check "Yes" or "No" to indicate whether or not a man was married to the child's natural mother and the child's
birth occurred within a year of the end of the marriage. Include the date the marriage ended. If "Yes", provide the man's
name and address.
The man may be the same man who is named as the father of the child in this affidavit, or he may be a different man.
Item 3c: Check “Yes” or “No” to indicate whether a man signed an acknowledgment of paternity before an
acknowledgment became a legal finding of paternity under State law. If “Yes”, attach a certified copy of the
acknowledgment.
The man may be the same man who is named as the father of the child in this affidavit, or he may be a different man.
NOTE: Some responding States may only need a regular copy, rather than a certified copy of this document.
Item 3d: Check "Yes" or "No" to indicate whether or not a man acted as and presented himself to be the child's father.
If "Yes", provide the man's name and address.
The man may be the same man who is named as the father of the child in this affidavit, or he may be a different man.
Item 3e: Check "Yes" or "No" to indicate whether or not genetic tests (e.g., blood tests) were completed to determine the
biological father of the child. If "Yes", attach the test results.
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CSF 11 0112 (Rev. 02/10/09)
SECTION II: (To be completed by Mother Only)
Item 1: Check "Yes" or "No" to indicate whether you (the mother) did or did not have sexual intercourse (sex) with
another man or other men during the 30 days before or the 30 days after the child was conceived ("Date Mother Got
Pregnant").
If you had sexual intercourse with another man or other men during this period (30 days before or 30 days after),
complete items 1a through 1c.
Item 1a: Provide the name(s) and address(es) of the other man/men.
Item 1b: Check "Yes" or "No" to indicate whether the other man/men are biologically related to the alleged father. If
"Yes", state the relationship (e.g., brother, cousin, etc). This may be relevant to genetic testing.
Item 1c: Explain why you do not believe the other man/men is/are the father of this child (e.g., prior exclusion by
genetic testing).
Item 2: Check "Yes" or "No" to indicate whether or not you were married at the time of the child's birth. If "Yes",
complete items 2a and 2b.
Item 2a: Provide the name and last known address of the man who was your husband at the time of the child's birth.
Item 2b: Explain why the husband is not the father. Attach appropriate documents.
Item 3: Be sure to enter the name of the father of this child. Check the appropriate answer for each statement (a - r) to
support the allegations of paternity against the alleged father. Remember to attach any necessary, relevant
documentation. This includes a certified copy of the birth certificate or the acknowledgment of paternity with the alleged
father's name on it; and other documents if available (e.g., letters or cards from the alleged father regarding the pregnancy
or the child).
NOTE: some responding States may only need a regular copy, rather than a certified copy, of these documents.
SECTION III
: (To be completed by Father Only)
Reminder: A putative father may petition for paternity establishment under UIFSA.
Check the appropriate answer for each statement (a - o). Remember to attach any necessary, relevant documentation.
This includes a certified copy of the birth certificate or acknowledgment of paternity with your name as the child's father
on it; and other documents if available (e.g., letters or cards from the mother regarding the pregnancy or the child).
Note: some responding States may only need a regular copy of a birth certificate or paternity acknowledgment, rather
than a certified copy.
SECTION IV: Provide any additional information not already covered which might be helpful in establishing paternity.
One example would be the alleged father's attendance in a child birth class with the mother.
If you are the mother, provide details to "Yes" answers to item 3, statements n through r in Section II.
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CSF 11 0112 (Rev. 02/10/09)
(n) Describe any food, clothing, gifts, or financial support the alleged father has provided for the child.
(o) Describe where and when the alleged father lived with the child.
(p) Provide dates and circumstances of any visits between the alleged father and the child.
(q) Describe any physical resemblance between the alleged father and the child. Attach photographs, if
available.
(r) Provide names and addresses of any witnesses to your relationship with the father. Consider friends and
relatives who were aware of the parties' dating, ongoing relationship, or cohabitation during the period of
conception.
If you are the father, provide details to "Yes" answers to statements k through o in Section III.
(k) Describe any food, clothing, gifts, or financial support you provided for the child.
(l) Describe where and when you lived with the child.
(m) Provide dates and circumstances of any visits between you and the child.
(n) Describe any physical resemblance between you and the child. Attach photographs, if available.
(o) Provide names and addresses of any witnesses to your relationship with the child's mother. Consider
friends and relatives who were aware of the parties' dating, ongoing relationship, or cohabitation during
the period of conception.
• The affidavit in support of establishing paternity must be signed by the mother or father seeking to establish
paternity.
• The signature requires a notary.
******************************************
The Paperwork Reduction Act of 1995
This information collection is conducted in accordance with 42 U.S.C. 651 et seq. and 45 CFR 303.7 of the child support
enforcement program. Standard forms are designed to provide uniformity and standardization for interstate case
processing. Public reporting burden for this collection of information is estimated to average under half an hour per
response. The responses to this collection are mandatory in accordance with the above statute and regulation. This
information is subject to State and Federal confidentiality requirements; however, the information will be filed with the
tribunal and/or agency in the responding State and may, depending on State law, be disclosed to other parties. An agency
may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number.
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CSF 11 0112 (Rev. 02/10/09)
