T1414 Attachment-1_Certificate-of-Parentage_2021-0323.pdf

State of New Jersey Certificate of Parentage

This legal document establishes paternity under New Jersey law. DO NOT sign this form unless you fully understand your rights and responsibilities as explained in the Legal Notices. Type or print in blue or black ink. The State of New Jersey WILL NOT accept any cross-outs,white-out or any other type of alteration.

Agency Completing Form Birth Facility Name (If Applicable)

Hospital/Birth Facility Registrar County Welfare Agency

Ch ild

Name as it Appears on Original Birth Certificate (First, Middle, Last) New Last Name To Be (If Applicable) Sex (Check One)

Male Female

Social Security Number Date of Birth (MM/DD/YYYY) City/Town of Birth County of Birth State of Birth

M ot he r

Name (First, Middle, Last) Phone Number Social Security Number

Date of Birth (MM/DD/YYYY) City/Town of Birth County of Birth State of Birth Country of Birth

Mailing Address City/Town State Zip Code

Employer Name and Address City/Town State Zip Code

Is/Was the mother married at the time of the child’s conception or birth? If yes, STOP! You must complete an Affidavit of Denial of Paternity to be submitted with this Certificate of Parentage if the mother is/was married at the time of the child’s conception or birth.Yes, the mother is/was married. No, the mother is not/was not married.

I certify under penalty of perjury that to the best of my knowledge, the above information is true and that the man named below is the only possible father of the child named on this Certificate. I have read, or have had read to me, the Legal Notices and understand the information provided. I hereby consent to the acknowledgment of paternity.

X Signature of Mother Date (Month DD, YYYY)

I, (Print Name), hereby certify that the above-named has identified herself to me as the signer.

X Signature of Notary Public or Witness Date (Month DD, YYYY)

Fa th er

Name (First, Middle, Last) Phone Number Social Security Number

Date of Birth (MM/DD/YYYY) City/Town of Birth County of Birth State of Birth Country of Birth

Mailing Address City/Town State Zip Code

Employer Name and Address City/Town State Zip Code

I certify under penalty of perjury that to the best of my knowledge, the above information is true and that I am the only possible father of the child named on this Certificate. I have read, or have had read to me, the Legal Notices and understand the information provided. I hereby consent to the acknowledgment of paternity.

X Signature of Father Date (Month DD, YYYY)

I, (Print Name), hereby certify that the above-named has identified himself to me as the signer.

X Signature of Notary Public or Witness Date (Month DD, YYYY)

REV.06-2018

This Certificate must be filed with the State IV-D Agency or its designee. If you have any questions about filing this Certificate, call 1-800-POP-6607.

DRAFT

REV.06-2018

PLEASE READ CAREFULLY. This legal document establishes paternity under New Jersey law. DO NOT sign the Certificate of Parentage unless you fully understand your rights and responsibilities as explained below.

LEGAL NOTICES

WHAT DOES IT MEAN TO SIGN THIS FORM?

Signing this Certificate of Parentage establishes paternity for your child. Paternity is the legal relationship between a father and his child. Parents who are not married to each other, may only legally establish paternity by signing this form or by going to court.

Paternity is legally established on the date that both parents voluntarily sign this form. If you wish to pursue genetic testing to verify paternity, DO NOT sign this form until you have received the test results. Once signed by both parents and witnessed or notarized, this form will have the same legal force and effect as a court judgment of paternity. As such, you may wish to consult an attorney before signing.

A signed Certificate of Parentage allows a parent to seek an order for child support without further court proceedings to establish paternity. The Certificate of Parentage may also be filed in court to serve as the basis for orders of custody and/or visitation. This means that the non-custodial parent may have the right to visit and establish a relationship with the child as both parents agree or as ordered by the court.

This form is not a public record. It will only be available to the parents and child named on the form, the child’s legal guardian or legal representative, and/or government officials in the conduct of their official duties.

WHAT ARE THE BENEFITS OF SIGNING THIS FORM?

Establishing legal paternity provides your child with specific benefits and opportunities.

By signing this form, your child will have two legal parents. This means that it may be easier for your child to access both parents’ medical histories and/or lineages.

Legal paternity may also qualify your child for financial benefits that may be available to the father such as healthcare coverage, life insurance, inheritance and dependent and/or survivors benefits from the Veterans Benefits Administration and/or Social Security Administration.

WHAT IF I CHANGE MY MIND?

This Certificate of Parentage may be rescinded at any time within 60 days of the date signed. Both parties must agree to rescind paternity by filing a Rescission of Certificate of Parentage with the Office of Vital Statistics and Registry.

If either party DOES NOT agree to rescind paternity, or if the Rescission of Certificate of Parentage is not filed with the Office of Vital Statistics and Registry within the 60-day timeframe, an action must be filed with the court.

If the Certificate of Parentage is rescinded within the 60-day timeframe, the father’s name and information will be removed from the child’s birth certificate. Please note, however, that both parties reserve the right to file a court action to establish paternity at a later date.

After this 60-day period, the parties may only challenge the Certificate of Parentage in court on the basis of fraud, duress or material mistake of fact and the party attempting to rescind the Certificate of Parentage must provide proof of fraud, duress or material mistake of fact.DRAFT