important ed above and facts about the putative fatherto claim paternity by submitting a rescission...
TRANSCRIPT
For more informationabout paternity, child support, or
genetic tests, contact:
Alternate forms of this publication for persons withdisabilities may be obtained by contacting the Missouri
Department of Health and Senior Services at 573-751-6378.Hearing and speech impaired citizens can dial 711.
AN EQUAL OPPORTUNITY/AFFIRMATIVEACTION EMPLOYER
Services provided on a nondiscriminatory basis.
Family Support DivisionP.O. Box 2320
Jefferson City, MO 65102-2320(800) 859-7999
Not
ice
of In
tent
to C
laim
Pat
erni
ty –
plea
se p
rint
or t
ype
Plea
se r
ead
care
fully
bef
ore
com
plet
ing
this
form
. Thi
s is a
lega
l doc
umen
t. Ty
pe o
r prin
t eve
ryth
ing
exce
pt y
our s
igna
ture
. Use
BLA
CK
INK
onl
y. P
leas
e co
mpl
ete
all i
tem
s. If
an
item
is n
ot k
now
n, e
nter
“U
nkno
wn”
.
Chi
ld’s
Inf
orm
atio
nC
hild
’s N
ame
(Fir
st, M
iddl
e, L
ast)
____
____
____
____
____
____
____
____
__D
ate
of B
irth
____
____
____
____
____
_
Plac
e of
Birt
h (C
ity, C
ount
y, St
ate)
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
Hos
pita
l of B
irth_
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
Mot
her’
s In
form
atio
nN
ame
(Fir
st, M
iddl
e, L
ast)
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
Mot
her’s
Mai
den
Nam
e__
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
___
Plac
e of
Birt
h (C
ity, S
tate
)___
____
____
____
____
____
____
____
__D
ate
of B
irth
(Mon
th, D
ay, Y
ear)
____
____
____
__
SSN
____
____
____
____
____
____
___
Educ
atio
n(H
ighe
st G
rade
Com
plet
ed)
____
__R
ace
____
____
____
____
Cur
rent
Add
ress
(Stre
et, C
ity, S
tate
, Zip
)___
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
_
Tele
phon
e N
umbe
r___
____
____
____
____
____
Empl
oyer
____
____
____
____
____
____
____
____
____
____
____
___
Fath
er’s
Inf
orm
atio
nN
ame
(Fir
st, M
iddl
e, L
ast)
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
__
Plac
e of
Birt
h (C
ity, S
tate
)___
____
____
____
____
____
____
____
__D
ate
of B
irth
(Mon
th, D
ay, Y
ear)
____
____
____
__
SSN
____
____
____
____
____
____
___
Educ
atio
n(H
ighe
st G
rade
Com
plet
ed)
____
__R
ace
____
____
____
____
Cur
rent
Add
ress
(Stre
et, C
ity, S
tate
, Zip
)___
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
_
Tele
phon
e N
umbe
r___
____
____
____
____
____
Empl
oyer
____
____
____
____
____
____
____
____
____
____
____
___
Paternityinformation formothers and fathers
Importantfacts about theputative fatherregistry
Stat
e of
____
____
_ C
ount
y__
____
__ su
bscr
ibed
and
swor
n be
fore
me
on th
is__
____
___
day
of
____
____
____
___
yea
r__
____
____
Not
ary
sign
atur
e__
____
____
____
____
____
____
____
____
__
Not
ary
Nam
e (ty
ped
or p
rinte
d)__
____
____
____
____
____
____
_C
omm
issi
on E
xpire
s:__
____
____
__
I hav
e re
ceiv
ed w
ritte
n or
ora
l not
ice
rega
rdin
g th
e Pu
tativ
e Fa
ther
Reg
istry
and
I un
ders
tand
my
alte
rnat
ives
, and
the
time
limits
for f
iling
. I u
nder
stan
dth
e re
spon
sibi
litie
s th
at a
rise
from
sig
ning
this
ack
now
ledg
men
t as
expl
aine
d in
the
pam
phle
t. I s
wea
r I a
m th
e na
tura
l fat
her o
f the
chi
ld n
amed
abo
ve a
ndit
is m
y in
tent
to c
laim
pat
erni
ty o
f thi
s ch
ild. I
am
requ
estin
g th
is a
ckno
wle
dgm
ent b
e re
gist
ered
with
the
Mis
sour
i Dep
artm
ent o
f Hea
lth a
nd S
enio
rSe
rvic
es’ “
Puta
tive
Fath
er R
egis
try”.
Mai
l to:
DH
SS/P
utat
ive
Fath
er R
egis
try, P
.O. B
ox 5
70, J
effe
rson
City
, MO
651
02-0
570.
Mus
t be
sign
ed in
the
pres
ence
of a
not
ary
F
athe
r’s S
igna
ture
____
____
____
____
____
____
____
____
____
_D
ate_
____
____
____
__A
pply
Not
ary
Embo
sser
or S
tam
p be
low
.
What is the putative father registry?The Putative Father Registry records the
names and addresses of fathers (or men whobelieve they are fathers) of children born outsideof marriage.
Why should a father put his nameon the Putative Father Registry?
The Putative Father Registry allows a man to“officially” claim he is the father of a child. Aman may want to do this before paternity islegally established if he can’t find the child’smother or if the mother doesn’t want to establishpaternity for the child.
The Putative Father Registry is used inadoption proceedings to identify the child’sfather, and promptly secure his consent toproceed with the adoption. A man who isconcerned that his child may be adopted withouthis consent should place his name on thePutative Father Registry before the child’s birthor within 15 days of the child’s birth in order tobe notified of an adoption proceeding for thechild. Failure to file in a timely manner shallwaive a man’s right to withhold consent to anadoption proceeding unless:
The person was led to believe through themother’s misrepresentation or fraud that:• The mother was not pregnant when in fact she
was; or• The pregnancy was terminated when in fact
the baby was born; or,• After the birth, the child died when in fact the
child is alive; and,The person upon the discovery of the misrepre-sentation or fraud satisfied the requirementswithin 15 days of that discovery.
Mis
sou
ri D
epar
tmen
t of
Hea
lth
an
d S
enio
r S
ervi
ces
AT
TN
: P
uta
tive
Fat
her
Reg
istr
yP.
O. B
ox 5
70Je
ffer
son
Cit
y, M
O 6
5102
-057
0
Aff
ixfi
rst-
clas
spo
stag
ehe
re
Notice of Intent to Claim PaternityA man’s name is added to the Putative Father
Registry when a court order is entered saying he isthe legal father. A man can also add his name to thePutative Father Registry by filing a Notice ofIntent to Claim Paternity or Acknowledgment ofPaternity with the Bureau of Vital Records.
Filing this notice does not establish legal pater-nity, but it does create an official record of theman’s claim to be the father of a child. The man’sname is not added to the child’s birth certificate. Aman should contact the Bureau of Vital Records ifhe wants to add his name to the registry.
A person filing a Notice of Intent to ClaimPaternity of a child shall notify the registry of anychange of address.
Who should register?A man who is not married to a child’s mother may
acknowledge paternity by completing the Notice ofIntent to Claim Paternity. The completed form mustbe notarized and mailed to the Putative FatherRegistry.
A person who has filed a Notice of Intent to ClaimPaternity may at any time revoke a Notice of Intentto Claim Paternity by submitting a rescission to theBureau of Vital Records
An un-revoked Notice of Intent to Claim Paternityof a child may be introduced in evidence by anyparty, other than the person who filed such notice,in any proceeding in which such fact may berelevant.
Voluntary acknowledgement ofpaternity
Parents can voluntarily establish paternity fortheir child by completing an Affidavit Acknowledg-ing Paternity any time after their child’s birth.When both parents properly complete and sign thisaffidavit, the man’s name is added to the child’sbirth certificate and the man becomes the legalfather of the child. This affidavit has the same effectas a court order establishing paternity and can beused as a basis for entering a child support order.
cut,
fold
and
sec
ure
wit
h ta
pe b
efor
e m
aili
ng