T1414 Attachment-2_Affidavit-of-Denial_2021-0323.pdf

State of New Jersey Affidavit of Denial of Paternity

This legal document should only be completed if the presumed father is NOT the biological father. 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.

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

Pr es um ed

F at 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

I certify under penalty of perjury that the child named on this Affidavit was conceived or born during my marriage to the mother named below or within 300 days after my marriage to the mother named below was terminated. I further certify that to the best of my knowledge, the above information is true and that I am not the father of the child named on this form. I understand that by signing this Affidavit, I am giving up my rights to be the father of the child named above and that my information will not appear on the child’s birth certificate. I have read, or have had read to me, the Legal Notices and understand the information provided. I hereby consent to the denial of paternity.

X Signature of Presumed 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)

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

I certify under penalty of perjury that the child named on this Affidavit was conceived or born during my marriage to the man named above or within 300 days after my marriage to the man named above was terminated. I further certify that to the best of my knowledge, the above information is true and that the man named above is not the father of the child named on this form. I understand that by signing this Affidavit, the presumed father’s information will not appear on my child’s birth certificate. I have read, or have had read to me, the Legal Notices and understand the information provided. I hereby consent to the denial 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)

REV.06-2018

This Affidavit must be filed with a completed Certificate of Parentage with the State or county child support office or the local registrar’s office in the community where the child was born. If you have questions about filing this Affidavit, call 1-800-POP-6607.

Agency Completing Form Birth Facility Name (If Applicable)

Hospital/Birth Facility Registrar County Welfare Agency

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REV.06-2018

PLEASE READ CAREFULLY. This legal document disestablishes a presumed father as the biological father of a child under New Jersey law. DO NOT sign the Affidavit of Denial of Paternity unless you fully understand your rights and responsibilities as explained below.

LEGAL NOTICES

WHAT DOES IT MEAN TO SIGN THIS FORM?

Paternity means fatherhood. If the mother is married at the time of birth or 300 days prior to birth, her husband is presumed to be the father of the child and does not have to take any further action to establish paternity. This form should not be signed if the husband (presumed father) wants his name and information on the child’s birth certificate.

By signing this Affidavit of Denial of Paternity, both the husband (presumed father) and wife are stating that the presumed father is not the legal father of the child named on this form.

Please place your initials below once you have read the information on this form.

Form Read In Mother’s Initials Form Read In Presumed Father’s Initials

English Spanish English Spanish

WHAT ARE THE LEGAL CONSEQUENCES OF SIGNING THIS FORM?

You may wish to consult an attorney before signing as this form has legal consequences as listed below:

• By signing this form, the presumed father gives up certain legal rights and responsibilities to be the father of the child, including the right to visitation and custody and the responsibility to support the child financially;

• By signing this form, the presumed father may not be required to support the child financially;

• By signing this form, the mother may give up the right to seek financial support from the presumed father and to have the presumed father’s name on the child’s birth certificate;

• Signing this form allows the presumed father to keep his information off the child’s birth certificate. If the form is not signed by the mother and the presumed father, the presumed father’s information will appear on the birth certificate;

• If this form is signed by the mother and the presumed father, the biological father and mother must complete a Certificate of Parentage to keep the husband’s information off the child’s birth certificate and to place the biological father’s information on the birth certificate; and

• This form may be filed with the court in a subsequent proceeding to help determine whether or not the presumed father is the child’s legal father.

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

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