Free Oregon 45 21 Form

•For 60 days after filing a Voluntary Acknowledgment of Paternity, either parent has the right to remove the father’s name from the birth certificate. Either the Mother or the Father can call the state office and request information about removing the father’s name from the record. A “Rescind of Paternity” form must be completed and postmarked within 60 days of the date that the Voluntary Acknowledgment of Paternity was filed. (ORS 109.070). The only valid reason for rescinding a Voluntary Acknowledgment of Paternity or Voluntary Acknowledgment of Paternity Affidavit is if either of the signers is unsure that the man who signed the form is in fact the father of the child.

•It is the responsibility of the parents to get the father’s name listed on the birth certificate if the family leaves the hospital or other health care facility without filling out a Voluntary Acknowledgment of Paternity (45-31). At any time thereafter, paternity can be established with the signing of the Voluntary Acknowledgment of Paternity Affidavit (45-21). This form must be signed by both parents in the presence of a notary public. Hospitals and other facilities may give this form to parents, or parents can go to their local county health department, child support program office, or call the State Vital Records office (Center for Health Statistics) to obtain this form. There is a $30.00 amendment fee for adding the father’s name to the birth record after the birth record is filed, unless the Affidavit is filed with either the local County health department or with the State Center for Health Statistics within 14 days of the birth.

According to federal law, parents must HEAR the “Statement of Rights and Responsibilities” which is printed on the back of the form. Staff may read the Statement or parents may read the Statement aloud to one another. An English language version can be found here: http://1.usa.gov/1qj5f7r and a Spanish language version here: http://1.usa.gov/1mmD8ZU

•County or state staff may assist parents in filling out this form, and may also notarize the signatures of the parents as long as they are not one of the parents or related to one of the parents, and are commissioned as a notary public.

•Parents must print and sign their own names before a notary. This information may not be typed or filled out by the notary.

INSTRUCTIONS

1)Please remember that this is a LEGAL DOCUMENT. Do not use white out. Minor corrections initialed by the person entering the information at the time the form is filled out will be accepted. No corrections will be accepted to the child’s surname. Unacceptable corrected forms or forms with blank spaces will be rejected and new forms will be required.

2)The Voluntary Acknowledgment of Paternity Affidavit form (45-21) is used after the mother has left the hospital or other birthing facility.

3)Once the affidavit is completed, the first page of instructions is removed and can be discarded. The second page is sent to the State Vital Records office, while the last two pages are given to the parents. Please remind them that these are their copies of this legal form. Because this document becomes part of a sealed file, the parents will not be able to receive additional copies in the future without a court order from an Oregon court.

4)Sections 1, 2, and 3 must be completed with all the required information pertaining to the

child, mother and father. The Date and County of Marriage in Section 4 must also be completed if applicable. Please verify that each section is complete and that the names match the birth certificate or birth worksheets.

Every effort should be made to gather all requested information about the mother and father. However, if information such as Social Security Number, Daytime Telephone Number, or Present Address, is not known, either “None” or “Unknown” should be entered in the space provided. If a parent refuses to give information, “Refused” should be entered in the space. No spaces should be blank.

Complete every field on the form. Enter "none" or "unknown" only for social security numbers,

telephone numbers, addresses, or Section 4 legitimation if information is not available.

5)Please make sure the Maiden Surname box is completed. If the mother is unsure what her maiden surname is, explain that it is the last name that is on her birth certificate, or her last name at birth.

6)If parents are signing the form at separate times before different notaries public, it is recommended that the first parent fill out the Child’s New Last Name in Section 1. The space for the Child’s New Last Name should not be left blank to avoid the second parent from changing the surname after the first parent has signed the form. Any white out or cross-outs of the child’s surname will invalidate the form.

7)Please note that the bottom portion of the affidavit is not to be completed without a notary present. Signature lines contain the most common errors on the paternity form.

Please be sure that the parents print their legal names (demonstrated as “A” in the example below), sign their legal names (demonstrated as “B” in the example below), and date their signatures (demonstrated as “C” in the example below). The Notary will complete all other lines on the bottom portion of the form. The date next to the parent signature must be the same date as appears next to the notary signature.

OFFICIAL SEAL

PHILLIP MORRIS

NOTARY PUBLIC‐OREGON

COMMISSION NO. 432111

MY COMMISSION EXPIRES MAY 10, 2012

OFFICIAL SEAL

LINDA SMITH

NOTARY PUBLIC‐OREGON

COMMISSION NO. 432165

MY COMMISSION EXPIRES AUGUST 21, 2013

The Voluntary Acknowledgment of Paternity Affidavit form is a legal document. It cannot be accepted if it is incomplete, has been altered, or was not signed in the presence of a notary. If the form has been completed incorrectly, both parents must complete and sign a new Voluntary Acknowledgment of Paternity Affidavit in the presence of a notary public. Unless filed within 14 days of the birth, requests to establish paternity using this form will incur a $30 amendment fee, plus a $20 fee for a new certified copy of the birth certificate.

For Additional Information

We appreciate your attention to detail when filling out this form, or when assisting families to fill out this form. If you are in need of additional assistance or would like training regarding the process of filling out this paperwork or filing with the vital records office, please call the Paternity Specialist at 971-673-1155, or the Vital Records Field Liaison at 971-673-1166. If either you or the family has questions regarding child support or other issues relating to child support, contact the state Child Support Division at 503-986-6166. Collect calls are accepted when calling child support offices.

The Center for Health Statistics provides postage-paid envelopes for mailing the forms. To order envelopes or forms, complete the order form available on our website at: http://public.health.oregon.gov/BirthDeathCertificates/RegisterVitalRecords/Documents/45- 43.pdf and fax it to 971-673-1201.