Form 1 Affidavit

AFFIDAVIT IN SUPPORT OF ESTABLISHING PATERNITY
Petitioner: Name (first, middle, last)
Social Security Number

IV-D Case:

Respondent: Name (first, middle, last)
Social Security Number

Non-IV-D Case:

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TANF
IV-E Foster Care
Medicaid Only
Former Assistance
Never Assistance

File Stamp

Responding IV-D Case Identifier
Responding Tribunal Number
Initiating IV-D Case Identifier
Initiating Tribunal Number

A Separate Affidavit Is Required for Each Child Needing Paternity Established.

SECTION 1
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
[ ] other; explain in Section IV

Child’s Full Legal Name

(first, middle last)

Child’s Date of Birth

Place of Birth

(City, County, State)

(Month, Day, Year)

Date Mother Got Pregnant
(Month, Year)

2.

Full Term Pregnancy
[ ] Yes

Where Mother Got Pregnant

[ ] No (If No, explain)

Mother’s Maiden Name (first, middle, last)

The child was conceived as a result of sexual intercourse between
Name (first, middle, last)

and me during the time stated above.
3.

(City, County, State)

a.

A man is named as the father on the child’s birth certificate.
If Yes, the man’s name and address are:

[ ] Yes (Attached certified copy)

b.

A man was married to the natural mother, and the child’s birth
occurred within a year of the end of the marriage.
If Yes, the man’s name and address are:

[ ] Yes

[ ] No

[ ] No

Date marriage ended
(Month, Day, Year)

c.

A man signed an acknowledgment of paternity before an
acknowledgment became a legal finding of paternity under
State law.

[ ] Yes (Attached certified copy)

d.

A man acted as and presented himself to be the child’s father.

[ ] Yes

[ ] No

[ ] Yes

[ ] No

[ ] No

If Yes, the man’s name and address are:

e.

Genetic tests were completed to determine the biological father
of the child. If Yes, attach results.

Affidavit in Support of Establishing Paternity

OMB 0970 – 0085 Expiration Date: 05/31/2014

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AFFIDAVIT IN SUPPORT OF ESTABLISHING PATERNITY, PAGE 2

Initiating IV-D Case Identifier

SECTION II (TO BE COMPLETED BY MOTHER ONLY)
1.

2.

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.

The name(s) and address(es) of the other man/men:

b.

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.)

c.

I do not believe the other man/men is/are the father because:

I was married at the time of this child’s birth

[ ] Yes

[ ] No

(If Yes, complete the following)

a.

Husband’s name (first, middle, last) and last known address:

b.

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

3.

is the father of this child. The following facts support my allegations of paternity:
a.

Name (first, middle, last)
We lived together.

[ ] Yes

[ ] No

Dates:

To

b.

I have told welfare officials that he is the father
of this child.

Location
[ ] Yes

[ ] No

c.

I told him that he was the father of the child.

[ ] Yes

[ ] No

d.

He is named as the father on the birth certificate.

[ ] Yes

[ ] No

[ ] Certified Copy Attached

e.

He signed an acknowledgment of paternity before an
acknowledgment became a legal finding of paternity
under State law.

[ ] Yes

[ ] No

[ ] Certified Copy Attached

f.

He admitted being the father of the child.

[ ] Yes

[ ] No

g.

He sent cards/letters regarding the pregnancy and/or about
the child.

[ ] Yes

h.

He was present at the birth of the child.

[ ] Yes

[ ] No

i.

He visited the child at the hospital following birth

[ ] Yes

[ ] No

j.

He offered to pay abortion expenses.

[ ] Yes

[ ] No

k.

He offered to pay medical expenses.

[ ] Yes

[ ] No

l.

He paid for birth related expenses.

[ ] Yes

[ ] No

m.
n.

He claimed the child on tax returns.
He has provided food, clothing, gifts or financial
support for the child.

[ ] Yes

o.
p.
q.

The child resembles him.

r.

There are witnesses to my relationship with him.

[ ]

Copies Attached

[ ] No

[ ]

Don’t Know

[ ] Yes

[ ] No

If Yes, explain in Section IV

He lived with the child.

[ ] Yes

[ ] No

If Yes, explain in Section IV

He visited the child.

[ ] Yes

[ ] No

If Yes, explain in Section IV

[ ] Yes

[ ] No

If Yes, explain in Section IV

[ ] Yes

[ ] No

[ ] Photo attached

[ ] No

(If Yes, list names and addresses and briefly describe relevant facts known by each under Section IV)
Affidavit in Support of Establishing Paternity

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AFFIDAVIT IN SUPPORT OF ESTABLISHING PATERNITY, PAGE 3

Initiating IV-D Case Identifier

SECTION III (TO BE COMPLETED BY FATHER ONLY)
The following facts support my belief and statements that I am the father of this child:
a.

The mother and I lived together.

[ ] Yes

[ ] No

b.
c.
d.

The mother told me that I am the father of the child.
I am named as the father on the birth certificate.
I signed an acknowledgment of paternity before an
acknowledgment became a legal finding of paternity
under State law.

[ ] Yes
[ ] Yes

[ ] No
[ ] No
[ ] No

e.
f.
g.
h.
i.
j.
k.

I was present at the birth of the child.
[ ] Yes
[ ] No
I visited the child at the hospital following birth
[ ] No
[ ] Yes
I offered to pay abortion expenses.
[ ] No
[ ] Yes
I offered to pay medical expenses.
[ ] No
[ ] Yes
I paid for birth related expenses.
[ ] No
[ ] Yes
I claimed the child on tax returns.
[ ] No
[ ] Yes
I have provided food, clothing, gifts or financial
support for the child.
[ ] Yes
[ ] No
If Yes, explain in Section IV
I lived with the child.
[ ] Yes
[ ] No
If Yes, explain in Section IV
I visited the child.
[ ] Yes
[ ] No
If Yes, explain in Section IV
If Yes, explain in Section IV
[ ] Yes
The child resembles me.
[ ] Photo attached
[ ] No
There are witnesses to my relationship with the
[ ] Yes
child’s mother
[ ] No
(If Yes, list names and addresses and briefly describe relevant facts known by each under Section IV)

Dates:

To

Location

l.
m.
n.
o.

[ ] Yes

[ ] Certified Copy Attached
[ ] Certified Copy Attached

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

Sworn to and Signed before me
this Date, County and State

Signature

Notary Public/Official and Title

Commission Expires

Affidavit in Support of Establishing Paternity

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INSTRUCTIONS FOR AFFIDAVIT IN SUPPORT OF ESTABLISHING PATERNITY
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. A
separate Affidavit is required for each allegation of paternity.

Italicized text that appears within a “box” refers to policy or provides additional information.

HEADING/CAPTION: [To be completed by the Child Support (IV-D) Worker]
• Identify the petitioner and respondent name (first, middle, last) and Social Security Number in the appropriate

spaces.
• Check the appropriate space to identify the type of case: TANF; IV-E Foster Care, Medicaid only; former assistance,

never assistance, or Non-IV-D.
TANF means the obligee’s family receives IV-A cash payments. A Medicaid only case is a case where the
obligee’s family receives Medicaid but does not receive TANF (IV-A cash payments).
• In the appropriate spaces, if applicable and if known, enter the Responding jurisdiction’s IV-D case identifier, and Tribunal

number.
Under “IV-D case identifier”, enter the number/identifier identical to the one submitted on the Federal Case
Registry, which is a left-justified 15-character alphanumeric field, allowing all characters except asterisk and
backslash, and with all characters in uppercase. Under “tribunal number”, you may enter the docket number,
cause number, or any other appropriate reference number that the responding State may use to identify the
case, if known. The Responding jurisdiction is the jurisdiction that is working the case at the request of the

initiating jurisdiction.
• In the appropriate spaces, enter the Initiating jurisdiction’s IV-D case identifier, and tribunal number.

Under “IV-D case identifier”, enter the number/identifier identical to the one submitted on the Federal Case
Registry, which is a left-justified 15-character alphanumeric field, allowing all characters except asterisk and
backslash, and with all characters in uppercase. Under “tribunal number”, you may enter the docket number,
cause number, or any other appropriate reference number which the initiating tribunal or agency has assigned
to the case. The initiating jurisdiction is the jurisdiction that referred the case to the responding jurisdiction for
services.

SECTION I: (Information to be completed or furnished by parent of the child)
Enter the full name (First, Middle, Last) of the parent or other individual completing the affidavit .

Item 1: Check whether you (the parent) are the natural mother or natural father of the child or, if other, explain your
relationship in Section IV.
• Enter the “Child’s Full Legal Name”, “Child’s Date of Birth”, and “Place of Birth”.
• “Date Mother Got Pregnant” - Enter the period of time when you believe the mother became pregnant (e.g., 4/89 or
from 4/89 to 5/89). Be sure to include both the month (or months) and the year when providing date(s). Be as specific
as possible.
• “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.



“Mother’s Maiden Name” - Enter the mother’s maiden name, if known.

Instructions for Affidavit in Support of Establishing Paternity

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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 3: The information in item 3 is intended to identify whether there is a presumed or legal father under State law. State
laws differ on whether and how a presumption of paternity is created.
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 certified 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. NOTE: Some responding States may only need a regular copy, rather than a certified copy of
this document.
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. Include the date the marriage ended. 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 a man signed an acknowledgment of paternity before an
acknowledgment became a legal finding of paternity under State law. If “Yes”, attach a certified copy of the
acknowledgment.
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. NOTE: Some responding States may only need a regular copy, rather than a certified copy of
this document.
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
biological 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 last known address of the man who was your husband at the time of the child’s birth.
Item 2b: Explain why the husband is not the father. Attach appropriate documents.

Instructions for Affidavit in Support of Establishing Paternity

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Item 3: Be sure to enter the name of the father of this child. Check the appropriate answer for each statement (a –
r) 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 or the acknowledgment of paternity with the alleged
father’s name on it; 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, rather than a certified copy, of these
documents.

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 -o). Remember to attach any necessary, relevant documentation.
This includes a certified copy of the birth certificate or acknowledgment of paternity with your name as the child’s father on
it; 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 n through r in Section II.
n)

Describe any food, clothing, gifts, or financial support the alleged father has provided for the child.

o)

Describe where and when the alleged father lived with the child.

p)

Provide dates and circumstances of any visits between the alleged father and the child.

q)

Describe any physical resemblance between the alleged father and the child. Attach photographs, if available.

r)

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 k through o in Section III.
k)

Describe any food, clothing, gifts, or financial support you provided for the child.

l)

Describe where and when you lived with the child.

m) Provide dates and circumstances of any visits between you and the child.
n)

Describe any physical resemblance between you and the child. Attach photographs, if available.

o)

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.



The affidavit in support of establishing paternity must be signed by the mother or father seeking to establish paternity.



The signature requires a notary.

The Paperwork Reduction Act of 1995
This information collection is conducted in accordance with 42 U.S.C. 651 et seq. and 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 under half an
hour per response. The responses to this collection are mandatory in accordance with the above statute and
regulation. 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

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