Louisiana Paternity Form

SECTION I. CHILD'S INFORMATION

This is a legal document. Complete in ink and do not alter.

Name of Child - First, Middle, Last (As it appears on birth certificate)

Date of Birth - (Month, Day, Year)

Place of Birth - City, State

Name of Hospital

Name of Child - First, Middle, Last (As the parents want it to appear on birth certificate)

SECTION II. MOTHER'S INFORMATION

husband.-

Name of Mother - First, Middle, Last

(Maiden Name)

Date of Birth - (Month, Day, Year)

Mother's Address

Mother's Phone Number

Ex

Mother's Place of Birth - City, State

Race (Circle) American Indian, Black, White, Asian

Mother's Social Security Number

If Other, List:

Husband/&

Circle One:

Yes

No

Mother's Occupation

Mother's Employer - Name & Address

Was Mother Married at Time of Birth

If Yes, Name and Address of Husband

Father

Does Mother Have Health Insurance

If Yes, Name of Insurance Company and Policy No.

State Medicaid:

Circle One:

Yes

No

Circle One:

Yes

No

Mother,

SECTION III. FATHER'S INFORMATION

Name of Father - First, Middle, Last

Date of Birth - (Month, Day, Year)

Support,

Father's Address

Father's Phone Number

Father's Place of Birth - City, State

Race (Circle) American Indian, Black, White, Asian

Father's Social Security Number

Childto

If Other, List:

Father's Employer - Name & Address

Father's Occupation

Copies

Father's Guardian (If Father under age 18) Print Name

Guardian's Address

Guardian's Signature

Does Father Have Health Insurance

If Yes, Name of Insurance Company and Policy No.

Records,

Circle One:

Yes

No

name appear on the Certificate of Birth of my child. I declare and affirm that I lived separate and apart from the legal presumptive father for a

minimum of one hundred

MOTHER: I certify that I am the MOTHER of the child named above and that all statements made herein are true and correct to the best

of my knowledge. I am

signing this Affidavit voluntarily and of my own free will. I acknowledge that the man named above is the biological father of my child. I give my consent to have his

Vital

and eighty days prior to the time of conception and have not reconciled since the beginning of the one hundred and eighty-day period.. I further acknowledge that I

have received oral and written notice of the legal rights and consequences resulting from my acknowledging the paternity of my child and I understand this notice.

of

__________________________________________

___________________________________________

Registrar

MOTHER'S SIGNATURE

DATE

WITNESS ____________________________________

WITNESS _____________________________________

to

State of Louisiana, Parish of _____________________________________

______________________________________________________________

Signature then PRINT name of Notary

Original

Signed and Affirmed before me on the

day of

___________________________

_______________________

,

.

State Notary Registration Number

My Commission expires on

COPIES:

FATHER: I certify that I am the biological FATHER of the child named above and that all statements made herein are true and correct to the best of my knowledge. I

am signing this Affidavit voluntarily and of my own free will. I acknowledge that I have received oral and written notice of the legal rights and consequences resulting

from my acknowledging the paternity of my child and I understand this notice.

OF

__________________________________________

___________________________________________

FATHER'S SIGNATURE

DATE

DISTRIBUTION

__________________________________________

___________________________________________

GUARDIAN'S SIGNATURE (If Father under age 18)

DATE

WITNESS ____________________________________

WITNESS _____________________________________

State of Louisiana, Parish of _____________________________________

______________________________________________________________

Signature then PRINT name of Notary

Signed and Affirmed before me on the

day of

___________________________

_______________________

,

.

State Notary Registration Number

My Commission expires on

HUSBAND/EX-HUSBAND OF THE MOTHER: I certify that I was married to the mother of this child at the time of conception or birth; however, I am not the biological

father. Further, I declare and affirm that I lived separate and apart from the mother for a minimum of one hundred and eighty days prior to the time of conception and

have not reconciled with her since the beginning of the one hundred and eighty-day period.

__________________________________________

___________________________________________

HUSBANS/EX-HUSBAN'S SIGNATURE

DATE

WITNESS ____________________________________

WITNESS _____________________________________

State of Louisiana, Parish of _____________________________________

______________________________________________________________

Signature then PRINT name of Notary

Signed and Affirmed before me on the

day of

___________________________

_______________________

,

.

State Notary Registration Number

My Commission expires on