Affidavit Of Parentage {DCH-0682}

AFFIDAVIT OF PARENTAGE Michigan Department of Health and Human Services Division for Vital Records and Health Statistics AOP Number We affirm under penalty of perjury that we are the natural parents of: State File Number First who was born in Middle on Hospital Name, City, County, State Last Suffix Date of Birth and that we sign this affidavit to establish the paternity for this child. We hereby consent that the name of the natural father may be included on the certificate of birth for the child. We wish the child's name to be recorded as: First Middle Last Suffix In signing this form, we understand that: (a) This is a legal document. (b) Completion of the affidavit is voluntary. (c) The mother has initial custody of the child, without prejudice to the determination of either parent's custodial rights, until otherwise determined by the court or agreed upon by the parties in writing and acknowledged by the court. This grant of initial custody to the mother shall not, by itself, affect the rights of either parent in a proceeding to seek a court order for custody or parenting time. (d) Either parent may assert a claim in court for parenting time or custody. (e) Both parents have a right to notice and a hearing regarding the adoption of the child. (f) Both parents have the responsibility to support the child and to comply with a court or administrative order for the child's support. (g) By signing this affidavit, we waive the following: (i) The right to blood or genetic tests to determine if the man is the biological father of the child. (ii) Any right to a court-appointed attorney, including the Prosecuting Attorney, to represent either party in a court action to determine if the man is the biological father of the child. (iii) The right to a trial to determine if the man is the biological father of the child. (h) In order to revoke the Affidavit of Parentage, an individual must file a claim as provided under the Revocation of Paternity Act (Michigan Compiled Law [MCL] 722.1437). Further, the mother states that she was not married when this child was born or conceived; or that this child, though born or conceived during a marriage, is not an issue of that marriage as determined by a court of law. FATHER'S INFORMATION First Name Middle Name Last Name Date of Birth: (MM/DD/YYYY) Place of Birth: (State or Country) Social Security Number MOTHER'S INFORMATION First Name Middle Name Last Name Date of Birth: (MM/DD/YYYY) Place of Birth: (State or Country) Social Security Number Current Address (Street, Apt. No., City, State, Zip) Current Address (Street, Apt. No., City, State, Zip) To the best of my knowledge, the above information is true: To the best of my knowledge, the above information is true: Father's Signature Date Mother's Signature Date NOTARY SECTION Notary Public in and for Acting in the county of Signature Signature and sworn to before me this Commission expiration date Printed Name day of 20 County, Michigan Notary Public in and for Acting in the county of Signature Signature and sworn to before me this Commission expiration date Printed Name day of 20 County, Michigan QUALIFIED WITNESS SECTION ­ Facility Use Only (if not notarized, complete as defined on reverse of form) Signature of Father's Witness Witness Place of Employment Witness Work Address (Street, City, State, Zip) Printed Name of Witness Signature of Mother's Witness Witness Place of Employment Witness Work Address (Street, City, State, Zip) Printed Name of Witness DCH-0682 (Rev. 4-16) By authority of Act 305 of 1996 as amended. 1 American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT OF PARENTAGE INSTRUCTIONS This form can be used to establish the parentage of a child and may be used to have information on the father of a child added to the certificate of birth for the child. This affidavit may be completed at the time of the child's birth or at any other time after the birth. Completion of this affidavit is voluntary. It indicates the parents wish to acknowledge parentage of a child. It is intended for use by couples who were not married at the time the child was conceived nor at the time of birth. In instances where the mother was married to someone other than the father when the child was conceived or delivered, a court ruling of her husband's nonpaternity is necessary in order to first establish that the child is not the husband's child. Proper completion of the form is very important. Forms that are not properly completed will not be accepted for filing. The form must be legible and must be typed or printed in ink. The affidavit must be signed by the mother and father in the presence of a Notary Public or a qualified witness. A qualified witness is an employee of one of the following: a hospital, publicly funded or licensed health clinic, pediatric office, Friend of the Court, Prosecuting Attorney, court, Michigan Department of Health and Human Services, county health agency, county records department, Head Start program, local social services provider, county jail, or state prison. The form may be signed and witnessed or notarized by both parents at different times. At a minimum, the following items must be provided: the full names of the child, the mother and the father; the date and place of the child's birth; the address of each parent; and the birth place of each parent. The same qualified witness and/or notary may serve as both the mother's qualified witness/notary and the father's qualified witness/notary, but (s)he must fill out the information in both the mother's and father's sections of the form. A qualified witness/notary must verify the identity of the mother and father before the qualified witness/notary signs the form by checking the mother's and father's identification. Examples of identification include a driver's license, passport, state-issued identification, etc. There is no fee for filing the affidavit with the Central Paternity Registry. Once filed, copies of the affidavit can be obtained by either parent, by the child, or by a guardian or legal representative of a parent or the child. Certified copies of the affidavit are available from the Central Paternity Registry for $34.00 (additional copies are $16.00 each) and can be requested at the time of filing. Adding a Father to the Birth Certificate ­ Establishing Paternity at the Hospital ­ If this affidavit is completed at the time of birth and provided to hospital staff before the birth certificate is prepared and filed, the birth