Acknowledgment of Paternity

I, ________________________________________ (name of father), of

________________________________________________________________________
________________________________________________________________________
(street address, city, county, state, zip code), being of sound mind and memory,
voluntarily, without coercion, and of my own free will, declare that I am the father of a
_________________________ (male or female) child born to _____________________
_______________________ (name of mother), of ______________________________
________________________________________________________________________
(street address, city, county, state, zip code), at _________________________________
____________________________ (name of hospital), ___________________________
________________________________________________________________________
(street address, city, county, state, zip code), on _________________________________
(date), and given the name of _________________________________________ (name
of child).

1Witness my signature on this the _____ day of

___________________________, 20_____.

____________________________________

____________________________________
(Name and Signature of Father)
STATE OF ____________________________
COUNTY OF __________________________

Personally appeared before me, the undersigned authority in and for said County
and State, on this _ day of _________________________________, 20_____, within
my jurisdiction, the within-named ____________________________________________
(Name of Father), who acknowledged that he executed the above and foregoing
instrument.

______________________________
NOTARY PUBLIC
My Commission Expires:
_________________________

Note: Acknowledgment may vary by state