Data Elements

OMB# 0970 – 0171
Expiration Date: 01/31/2027
Table 1: Complete List of Required and Optional Data Elements

REQUIRED DATA ELEMENTS

OPTIONAL DATA ELEMENTS

1. Current Full Name

1. Daytime Phone Number

(mother, father and child)

(mother and father)

2. Social Security Number

2. Birthplace - mother and father

(mother and father)

(city, county & state)

3. Date of Birth

3. Hospital of Birth

(mother, father and child)

(child)

4. Address

4. Sex of Child

(mother and father)
5. Birthplace - child

5. Father's Employer

(city, county & state)
6. Legal Finding (60 day rescission)

6. Ethnicity of Father

7. Rights and Responsibilities, Alternatives

7. Medical Insurance

and Consequences
8. Signature Lines for Parents

8. Maiden Name of Mother
9. Place Where Acknowledgment or Affidavit

9. Notary Seals/Witnesses: Signature Lines

Was Completed
10. Offer of Name Change
(child)
11. Minors: Signature Line for Guardian Ad
Litem or Legal Guardian
12. Three-Way Signature Offered on Form
(husband, wife, and biological father)
13. An advisory to parents that they may wish
to seek legal counsel or obtain a genetic test
before signing
14. A statement concerning the custody status
of the child vis-a-vis State law

The Paperwork Reduction Act of 1995 (Pub. L. 104-13): STATEMENT OF PUBLIC BURDEN: The purpose of this information
collection is to provide the required and optional data elements for the state-developed affidavit used by hospitals, birth record
agencies, and other partners participating in a state's voluntary paternity establishment program. Public reporting burden for this
collection of information is estimated to average .17 hours per process, including the time for reviewing instructions, gathering and
maintaining the data needed, and reviewing the collection of information. This collection of information is required for specifying the
minimum requirements for voluntary acknowledgment of paternity (section 452(a)(7) of the Social Security Act). An agency may
not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the
Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0171 and the
expiration date is 01/31/2027. If you have any comments on this collection of information, please contact OCSS by email at
[email protected]