important ed above and facts about the putative fatherto claim paternity by submitting a rescission...

2
For more information about paternity, child support, or genetic tests, contact: Alternate forms of this publication for persons with disabilities 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/AFFIRMATIVE ACTION EMPLOYER Services provided on a nondiscriminatory basis. Family Support Division P.O. Box 2320 Jefferson City, MO 65102-2320 (800) 859-7999 Notice of Intent to Claim Paternity please print or type Please read carefully before completing this form. This is a legal document. Type or print everything except your signature. Use BLACK INK only. Please complete all items. If an item is not known, enter “Unknown”. Child’s Information Child’s Name (First, Middle, Last) __________________________________ Date of Birth _____________________ Place of Birth (City, County, State) ____________________________________________________________________ Hospital of Birth ___________________________________________________________________________________ Mother’s Information Name (First, Middle, Last) __________________________________________________________________________ Mother’s Maiden Name _____________________________________________________________________________ Place of Birth (City, State) _________________________________ Date of Birth (Month, Day, Year) ______________ SSN ___________________________ Education (Highest Grade Completed) ______ Race ________________ Current Address (Street, City, State, Zip) ________________________________________________________________ Telephone Number _______________________ Employer _______________________________________________ Father’s Information Name (First, Middle, Last) __________________________________________________________________________ Place of Birth (City, State) _________________________________ Date of Birth (Month, Day, Year) ______________ SSN ___________________________ Education (Highest Grade Completed) ______ Race ________________ Current Address (Street, City, State, Zip) ________________________________________________________________ Telephone Number _______________________ Employer _______________________________________________ Paternity information for mothers and fathers Important facts about the putative father registry State of _________ County ________ subscribed and sworn before me on this _________ day of _______________ year __________ Notary signature ____________________________________ Notary Name (typed or printed) ___________________________ Commission Expires: ____________ I have received written or oral notice regarding the Putative Father Registry and I understand my alternatives, and the time limits for filing. I understand the responsibilities that arise from signing this acknowledgment as explained in the pamphlet. I swear I am the natural father of the child named above and it is my intent to claim paternity of this child. I am requesting this acknowledgment be registered with the Missouri Department of Health and Senior Services’ “Putative Father Registry”. Mail to: DHSS/Putative Father Registry, P.O. Box 570, Jefferson City, MO 65102-0570. Must be signed in the presence of a notary Father’s Signature _____________________________________ Date _______________ Apply Notary Embosser or Stamp below.

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Page 1: Important ed above and facts about the putative fatherto Claim Paternity by submitting a rescission to the Bureau of Vital Records An un-revoked Notice of Intent to Claim Paternity

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

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Paternityinformation formothers and fathers

Importantfacts about theputative fatherregistry

Stat

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the

time

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ary

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sser

or S

tam

p be

low

.

Page 2: Important ed above and facts about the putative fatherto Claim Paternity by submitting a rescission to the Bureau of Vital Records An un-revoked Notice of Intent to Claim Paternity

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.

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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.

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