Free Document - New York

AFFIDAVIT IN SUPPORT OF ESTABLISHING PATERNITY
Petitioner

Respondent

[ ] IV-D Non Public Assistance [ ] IV-D Non PA Medicaid [ ] Full Services [ ] Medical Services Only [ ] IV-D Public Assistance [ ] IV-E Foster Care (IV-D Case) [ ] Non IV-D

File Stamp

Responding IV-D Case No. _________________________________ Responding Docket No. ____________________________________

Initiating IV-D Case No. ___________________________________ Initiating Docket 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
Child's Full Name
(First, Middle, Last)

Child's Date of Birth
(Month, Date, Year)

Place of Birth

(City, County, State)

Date Mother Got Pregnant
(Month, Date, Year)

Full Term Pregnancy [ ] Yes [ ] No (If No, explain)

Where Mother Got Pregnant

(City, County, State)

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: b.

[ ] Yes (Attach copy) [ ] No

A man was married to the natural mother, and the child's birth occurred within a year of the end of the marriage. [ ] Yes [ ] No If Yes, the man's name and address are:

c.

A man signed an acknowledgment of paternity. If Yes, the man's name and address are:

[ ] Yes (Attach copy) [ ] No [ ] Yes [ ] No [ ] No
Page 1 of 3

d.

A man acted as and presented himself to be the child's father. If Yes, the man's name and address are:

e.

Genetic tests were completed to determine the father of the child. If Yes, attach results.
OMB No. 0970 - 0085

[ ] Yes

Affidavit in Support of Establishing Paternity

AFFIDAVIT IN SUPPORT OF ESTABLISHING PATERNITY, PAGE 2 SECTION II (TO BE COMPLETED BY MOTHER ONLY)

Initiating IV-D Case No.

1. 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. b. The name(s) and address(es) of the other man/men: 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.): I do not believe the other man/men is/are the father because:

c.

2. I was married at the time of this child's birth. [ ] Yes [ ] No. a. b. Husband's name
(first, middle, last)

(If Yes, complete the following).

and last known address:

Explain why the husband is not the father of this child and attach all appropriate documents, including divorce decree, blood test results and prior findings of nonpaternity, if any:

3. _______________________________ is the father of this child. The following facts support my allegations of paternity:
Name (First, Middle, Last)

a. We lived together.

[ ] Yes [ ] No ] Yes ] Yes ] Yes ] Yes ] Yes ] Yes ] Yes ] Yes ] Yes ] Yes ] Yes [ [ [ [ [ [ [ [ [ [ [ ] No ] No ] No ] No ] No ] No ] No ] No ] No ] No ] No ] No ] No ] No ] No

Dates:_________To_________

Location_____________________

b. I have told welfare officials that he is the father of this child. [ c. I told him that he was the father of the child. [ d. He is named as the father on the birth certificate. [ e. He admitted being the father of the child. [ f. He signed an acknowledgment of paternity. [ g. He sent cards/letters regarding the pregnancy and/or about the child. [ h. He was present at the birth of the child. [ i. He visited the child at the hospital following birth. [ j. He offered to pay for an abortion/medical expenses. [ k. He paid for birth related expenses. [ l. He claimed the child on tax returns. [ m. He has provided food, clothing, gifts or financial support for the child. [ n. He lived with the child. [ o. He visited the child. [ p. The child resembles him. [ ] Photo attached [ q. There are witnesses to my relationship with him. [ ] Yes

[ ] Certified Copy Attached [ ] Certified Copy Attached [ ] Copies Attached

[ ] Don't Know
If Yes, explain in Section IV If Yes, explain in Section IV If Yes, explain in Section IV If Yes, explain in Section IV

] Yes [ ] Yes [ ] Yes [ ] Yes [ [ ] No

(If Yes, list names and addresses and briefly describe relevant facts known by each under Section IV)

Affidavit in Support of Establishing Paternity

Page 2 of 3

AFFIDAVIT IN SUPPORT OF ESTABLISHING PATERNITY, PAGE 3 SECTION III (TO BE COMPLETED BY FATHER ONLY)

Initiating IV-D Case No.

The following facts support my belief and statements that I am the father of this child:

a. The mother and I lived together. b. c. d. e. f. g. h. i. j.

[ ] Yes [ ] No

Dates:_________To_________

Location_____________________

The mother told me that I am the father of the child. [ ] Yes [ ] No I am named as the father on the birth certificate. [ ] Yes [ ] No [ ] Certified Copy Attached I signed an acknowledgment of paternity. [ ] Yes [ ] No [ ] Certified Copy Attached I was present at the birth of the child. [ ] Yes [ ] No I visited the child at the hospital following birth. [ ] Yes [ ] No I offered to pay for an abortion/medical expenses. [ ] Yes [ ] No I paid for birth related expenses. [ ] Yes [ ] No I claimed the child on tax returns. [ ] Yes [ ] No I have provided food, clothing, gifts or financial support for the child. [ ] Yes [ ] No If Yes, explain in Section IV k. I lived with the child. [ ] Yes [ ] No If Yes, explain in Section IV l. I visited the child. [ ] Yes [ ] No If Yes, explain in Section IV m. The child resembles me. [ ] Photo attached [ ] Yes [ ] No If Yes, explain in Section IV n. 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

_____________________________________________________________________

Affidavit in Support of Establishing Paternity

Page 3 of 3

INSTRUCTIONS FOR AFFIDAVIT IN SUPPORT OF ESTABLISHING PATERNITY

OMB No. 0970 - 0085

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. HEADING/CAPTION: [To be completed by the Child Support (IV-D) Worker] # # Identify the petitioner and respondent in the appropriate spaces. Check the appropriate space to identify the type of case: IV-D Non Public Assistance; IV-D Non Public Assistance Medicaid (indicate whether receiving Full Services or Medical Services Only); IV-D Public Assistance; IV-E Foster Care; or Non IV-D. IV-D means the case is being worked by the State or local child support enforcement agency (i.e., IV-D agency). Public Assistance means the obligee's family receives IV-A cash payments [IV-A was formerly called Aid to Families with Dependent Children (AFDC) and is now called Temporary Family Assistance]. A IV-D Non Public Assistance Medicaid case is a case where the obligee's family receives Medicaid but does not receive Public Assistance (IV-A cash payments). Under "Responding IV-D Case No." and "Responding Docket No.", enter appropriate case and docket numbers that the responding State uses to identify the case, if applicable and if known. Under "docket number", you may enter the docket number, cause number, or any other appropriate reference number. Under "Initiating IV-D Case No." and "Initiating Docket No.", enter appropriate case and docket numbers which your IV-D agency or local tribunal has assigned to the case. Under "docket number", you may enter the docket number, cause number, or any other appropriate reference number.

#

#

SECTION I: (Information to be completed or furnished by parent of the child) Enter the full name (First, Middle, Last) of the parent completing the affidavit. Item 1: Check whether you (the parent) are the natural mother or natural father of the child. Enter the "Child's Full Name", "Child's Date of Birth", and "Place of Birth". "Date Mother Got Pregnant" - Enter the date or period of time when you believe the mother became pregnant (e.g., 4/1/89 or from 4/1/89 to 5/1/89). Be sure to include the year when providing date(s). Be as specific as possible, providing an individual date, multiple dates or a range of dates. If additional space is needed, continue in Section IV or on an attached separate sheet. "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.
Instructions for Affidavit in Support of Establishing Paternity--Page 1

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 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 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. 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. 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 or not a man signed an acknowledgment of paternity. If "Yes", attach a copy of the acknowledgment 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. 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 father of the child. If "Yes", attach the test results. 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 address of 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 - q) 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 with the
Instructions for Affidavit in Support of Establishing Paternity--Page 2

alleged father's name on it; a certified copy of a paternity acknowledgment; 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 of a birth certificate or paternity acknowledgment, rather than a certified copy. 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 - n). Remember to attach any necessary, relevant documentation. This includes a certified copy of the birth certificate with your name as the child's father on it; a certified copy of a paternity acknowledgment; 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 m through q in Section II. (m) (n) (o) (p) (q) Describe any food, clothing, gifts, or financial support the alleged father has provided for the child. Describe where and when the alleged father lived with the child. Provide dates and circumstances of any visits between the alleged father and the child. Describe any physical resemblance between the alleged father and the child. Attach photographs, if available. 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 j through n in Section III. (j) (k) (l) (m) (n) Describe any food, clothing, gifts, or financial support you provided for the child. Describe where and when you lived with the child. Provide dates and circumstances of any visits between you and the child. Describe any physical resemblance between you and the child. Attach photographs, if available. 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.

Instructions for Affidavit in Support of Establishing Paternity--Page 3

****************************************** The Paperwork Reduction Act of 1995 This information collection is conducted in accordance with 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 one hour per response. The responses to this collection are mandatory in accordance with 45 CFR 303.7. 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.

Instructions for Affidavit in Support of Establishing Paternity--Page 4