Affidavit Of Parentage
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1
2STATE OF MICHIGAN
DEPARTMENT OF COMMUNITY HEALTH
Vital Records and Health Data Development
State File Number
AFFIDAVIT OF PARENTAGE
(PLEASE PRINT OR TYPE)
We affirm under penalty of perjury that we are the natural parents of:
(First)
(Middle)
(Last)
who was born in
on
(Hospital Name, City, County, State)
(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)
In signing this form, we understand that:
a)
This is a legal document.
b)
Completion of the acknowledgment 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 acknowledgment, 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 an acknowledgment of parentage, an individual must file a claim as provided under Michigan Compiled Law 722.1011.
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
MOTHER
Name
Name
(Father’s Name – Printed)
(Mother’s Name – Printed)
Current Address
Name and Street Number
Current Address
Name and Street Number
City
State
ZIP Code
City
State
ZIP Code
Date of Birth
Date of Birth
State or Country of Birth
State or Country of Birth
Social Security Number
Social Security Number
To the best of my knowledge, the above information is true
To the best of my knowledge, the above information is true
(Signature of Father)
(Signature of Mother)
Signed and sworn to before me in
County,
Signed and sworn to before me in
County,
Michigan, on
Michigan, on
,
,
Notary Public, State of Michigan, County of:
Notary Public, State of Michigan, County of:
(Notary Public’s Signature)
(Notary Public’s Signature)
(Notary Public’s Name – Printed or Typed)
(Notary Public’s Name – Printed or Typed)
My commission expires
My commission expires
DCH-0682w (06/2006) By authority of Act 305 of 1996
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