‘THERE IS NO LAW THAT REQUIRES THE COMPLETION OF A PATERNITY AFFIDAVIT: however. itis the responsibilty ofthe “person in aendange” ala bith o advise the mother of child horn ou of wedlock ofthe option to execute A Paerity Aidit IF THIS PATERNITY AFFIDAVIT IS NOT COMPLETED, the sumame ofthe child mus be recorded inthe legal sumame of the mother (IC 16-37-23) unless paternity was established by prior court order ha seciis the suman in which the birth shall bbe ecorded. In adition, ino Paternity AMfidavit is completed, paternity will not be shown on cerified capes ofthe birt record issued bythe local heal department or the Indiana State Depariment of Health unless patemity is established by court erdr or the parents subsequently marry each other, eport this ation, and request the amendment of the original bin certificate, ESTABLISHMENT OF PATERNITY BY COURT ORDER. If patemity was established by judicial decree prior tote bith of this child his for should he completed and the court order, Paternity Affidavit. and an original Indiana Certificate of Live Birth ‘shouldbe sent to the local health department atthe same time REBUTTAL OF THE PATERNITY AFFIDAVIT: The bith fcs established by the Patrity Adavit become an integral part (ofthe ceticate information recorded atthe local heath deparement and the Indiana State Deparment of Health Any request tamend, revoke, of rebut the facts of binh and paterity established bythe Paternity Affidavit, pursuant to IC 1637-2-10, requires & cou onde. ‘A Patoty Affidavit may he executed though a local health depanment. The Patemity Afidavit must be completed before the ‘hid has ached the age of emancipation [ 1C 16-37-22 1(2) 2) VOID AFFIDAVITS OF PATERNITY: [A Potemity Affidavit snot vali fi is executed afer the mothcr ofthe child has executed a consent to adoption ofthe child and petition to adopt the child has been led. RIGHTS AND RESPONSIBILITIES By signing his document, | acknowledge that have ead and understand the following: 1 That this affidavit established paternity and gives rise t parental rights and responsibliies including the right of the child’ mother o the IV-D agency 1o collect child support and tha a child support order canbe established based on this ‘document without any fuer evidence concerning te issue of pater. That if this afidavit is completed there will be no hearing related to the patemity of the cildlen) included in the saat a hat if this affidavit is completed. paternity legally established, ‘ ‘That an action to have the Paternity Affidavit set aside must be filed in a court with jurisdiction over paternity within sixty (60) days afer the date his aidavits completed s ‘That by contacting the Prosecuting Attomey’s Office in my county. I can pursue the following child support services ‘tvough the IV-D program by ‘A, Locating absent parents whose whereabouts are unknown, B. Securing a cour order for the payment of child suppor. and C—_Enforeement of suppor order. WRITTEN SIGNATURE OF FATHER, WRITTEN SIGNATURE OF MOTHER. Subscribed and. sworn to before me the undersigned @ Notary Public ta and Tor said county, thix_day ot .19__ Signature of Notary Public County of Residence My commision expires ANY OMNMER CHANGES TO THISRECORD MAY BE MADE BY COURT ORDER ONETINDIANA STATE DEPARTMENT OF HEALTH LOCAL HEALTH DEPARTMENT PATERNITY AFFIDAVIT SF 48467 (7-97) STATUTORY AUTHORITY IC 16-87-2221 STATE OFFICE USE ONLY GENERAL INSTRUCTIONS: WRITTEN signatures mast be 3 in BLACK INK ONLY. THIS FORM MUST BE TYPED, =D AD State otniana Libe We, and . have read and understand Father) (Mother) the general information provided about this affidavit, being duly sworn upon oath deposes and says: ‘SECTION A- ACKNOWLEDGMENT OF PATERNITY BY FATHER That ‘am the natural father of a child born 10 (Father) (male/female) at (Same of Mother at Time of Binh oF Chia) (ston. Day. Year) (Wospial or Sret Adares) (Gy) (County) (Siate) ‘Name of Child at birth js ‘ACTS OF BIRTH “Your SSA ls being requested by ths State ageney in accordance with 20 S.C.408 (¢)(2}(C) i. Diseosure is mandatory under Full LEGAL Name st, m,n), Date of Bit tomo. da. yea0) Place or Bin sss (Stat or foreign country) Adress of Father cy _state tip__ SECTION C - MOTHER'S CERTIFIABLE FACTS OF BIRTH “Your SS# is being requested by this State agency in accordance with 42 USC. 408(e12KC (i), Disclosure ismandatory under this federal law Full LEGAL Name title. as MAIDEN SURNAME Dare oF ih tron, das. yee) Place of Binh Lasse (State or foreign country) Address of Mother City State Indiana Certificate of Live Birth shall be recorded as: (Fit. Mie. Last) The completion of the Paterity Affidavit permits the Fling ofan original Indiana Cerificate of Live Birth for a child thom out oF wedlock that includes the name of the father. The name of the chikl shall he that which is mutually agreed upon by the parents. and the name and birthplace (state or foreign country) of both parents will be shown vn future cxnified copies ofthe hin certificate ise by the local health department of the Indiana State Department of leat