Form 3940 - Paternity Acknowledgment - State Of Georgia
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2PATERNITY ACKNOWLEDGMENT – STATE OF GEORGIA
(Print or type all information in black or blue permanent ink. This form may be copied.)
State File Number: _____________________ Facility:_____________________________
PLEASE NOTE: This form cannot be completed if the mother was married to anyone within the 10 months prior to the birth
of this child or if, for any other reason, there is another father of this child listed on the child’s birth certificate.
_________________________________________________________ is the biological (natural) father of the child born to
FATHER’S | First Name
Middle
Last / Generation (Jr., III, etc)
_________________________________________________________ on the _____ day of __________, 20 ____ in
MOTHER’S | First Name
Middle
Last
Maiden Name
__________________ County, Georgia. We are requesting to have the name of the biological father placed on the birth certificate and
that the child be named:
__________________________________________________________________________________________________
CHILD’S
| First Name
Middle
Last Name /Generation
Mother’s Information:
Address____________________________________________________________________
Number and Street Name
City
State
Zip Code
Date of Birth: ___________________
Social Security Number ___________________________
Employer ______________________
Employer’s Address _____________________________________________
Father’s Information:
Address____________________________________________________________
Number and Street
City
State
Zip Code
Date of Birth: ___________________ State of Birth ______ Social Security Number ______________________________
Employer ______________________
Employer’s Address ____________________________________________
I understand that either parent may withdraw this paternity acknowledgment, without penalty, within 60 days from the date
of his/her signature. I have been informed of my rights and responsibilities as explained on the reverse side of this form.
___________________________________
____________________________________
Mother’s Signature
Father’s Signature
Acknowledged to be true and correct before me on
Acknowledged to be true and correct before me on
this _____ day of __________________, 20_____.
this _____ day of_________________, 20_____.
__________________________________________________
___________________________________________________
0
0
Notary Public
Notary Public
My term expires on ______________, 20____
My term expires on ______________, 20____
Identification presented by Mother ____________________________
Identification presented by Father ____________________________
ACKNOWLEDGMENT OF LEGITIMATION
We
, the mother and biological father, voluntarily consent and agree that the relationship between the child and the father shall be
considered legitimate for all purposes under law pursuant to O.C.G.A. §19-7-21.1. Note: This section does not apply if the child is
over one year of age at the time this document is signed.
___________________________________
____________________________________
Mother’s Signature
Father’s Signature
Acknowledged to be true and correct before me on
Acknowledged to be true and correct before me on
this _____ day of __________________, 20_____.
this _____ day of_________________, 20_____.
__________________________________________________
___________________________________________________
0
0
Notary Public
Notary Public
My term expires on ______________, 20____
My term expires on ______________, 20____
Identification presented by Mother ____________________________
Identification presented by Father ____________________________
NOTE: By signing this document, you are stating that you have read and understood all of its provisions, including those printed
on the reverse side of this document and that the facts stated on this document are true. Pursuant to O.C.G.A. §31-10-31, anyone
making a false statement on this document may go to prison for up to five years and fined up to $10,000. Photo ID is required of
all individuals signing this document.
Form 3940 (Rev. 7-10)
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