Free State of Minnesota - Minnesota

State of Minnesota
County

District Court
Judicial District: Court File Number: Case Type Family Court

Select County
In the Matter of:
Petitioner

DENIAL OF PATERNITY
vs.
Respondent

I,

, state as follows:

1.

I am _______ years of age; and reside at
(Street Address) (City) (State) (County)

2.

I have been advised _____________________________ is the mother of a ______________ child
(Male/Female)

named ____________________________ born or expected to be born on _________________ and I have registered with the Father's Adoption Registry as father of this child. 3. 4. I now deny that I am the father. My denial at this time will not subject me to any criminal liability. I enter my appearance in this case and waive service of summons and other pleading.

OATH
I have been sworn and say under oath I have read and understand this form. The facts it contains are true and correct to the best of my knowledge. I have signed this document freely and voluntarily.

Sworn/affirmed before me this _________ of _____________, _______

Signature:
Sign only in presence of notary or court clerk

Print Name: Street Address:

Notary Public/Court Deputy

City/State/Zip: Telephone:

ADO102

State

ENG

Rev 9/99

www.courts.state.mn.us/forms

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