AOP-2023-0010288
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
N. C. VITAL RECORDS
AFFIDAVIT OF PARENTAGE FOR CHILD BORN OUT OF WEDLOCK
(Type or print all information)
We hereby affirm that
(Full Name of Child)
(Social Security Number, if Available)
who was born
, in
at
(Date of Birth)
(City, County of Birth)
(Name of Hospital or Institution--If neither,street address)
is the natural child of
(Full Name of Father)
(Social Security Number)
(Father's Address)
and
(Mother's Full Name Prior to First Marriage)
(Social Security Number)
(Mother's Address)
(County of Residence)
Affidavit signed at
(Name of Hospital, Child Support Services, Clerk of Court, Other)
INFORMATION CONCERNING THE FATHER
Race
Date of Birth
(Specify White, Black, Am. Indian, etc.)
(Month, Day, Year)
Is father of Hispanic origin?
Yes
No
If yes,
(Specify Cuban, Mexican, Puerto Rican, etc.)
Education
Birthplace
(Highest Grade Completed Elem 1-8;High 9-12; Col 13-17+)
(County, State or Foreign Country)
CERTIFICATION OF PARENTS
I acknowledge that I have received and understand the oral instructions and the information on the back of this form that explains the
purpose and consequences of signing this document, including possible requirements to pay child support.
Mother
I am the natural mother and the man named above is the natural father
of the child named above. I consent to the assertion of paternity
by the putative father. I also declare and affirm that:
(check one)
Father
I acknowledge that I am the natural father of the child named above.
I understand that this Affidavit shall,when signed and sworn by both
parents,have the same force and effect as a judgement of the court in
establishing my paternity of the above-named child.
I was unmarried at my child's conception or birth,
I was married to someone other than the above-named father.
(See Instructions, #1 on back)
Signature of Mother
(If minor mother- parent, guardian or other adult may sign,but it is not required)
State of
County of
Sworn to and subscribed before me this
day of
,
(SEAL)
NOTARY PUBLIC
My commission expires
Signature of Father
(If minor father- parent, guardian or other adult may sign, but it is not required)
State of
County of
Sworn to and subscribed before me this
day of
,
(SEAL)
NOTARY PUBLIC
My commission expires
DHHS 1660(Revised 3/2019)
Vital Records(Review 3/2021)
VITAL RECORDS COPY
INSTRUCTIONS ON REVERSE SIDE
Page 1 of 4
4/6/2023
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
N. C. VITAL RECORDS
AFFIDAVIT OF PARENTAGE FOR CHILD BORN OUT OF WEDLOCK
(Type or print all information)
We hereby affirm that
(Full Name of Child)
(Social Security Number, if Available)
who was born
, in
at
(Date of Birth)
(City, County of Birth)
(Name of Hospital or Institution--If neither,street address)
is the natural child of
(Full Name of Father)
(Social Security Number)
(Father's Address)
and
(Mother's Full Name Prior to First Marriage)
(Social Security Number)
(Mother's Address)
(County of Residence)
Affidavit signed at
(Name of Hospital, Child Support Services, Clerk of Court, Other)
INFORMATION CONCERNING THE FATHER
Race
Date of Birth
(Specify White, Black, Am. Indian, etc.)
(Month, Day, Year)
Is father of Hispanic origin?
Yes
No
If yes,
(Specify Cuban, Mexican, Puerto Rican, etc.)
Education
Birthplace
(Highest Grade Completed Elem 1-8;High 9-12; Col 13-17+)
(County, State or Foreign Country)
CERTIFICATION OF PARENTS
I acknowledge that I have received and understand the oral instructions and the information on the back of this form that explains the
purpose and consequences of signing this document, including possible requirements to pay child support.
Mother
I am the natural mother and the man named above is the natural father
of the child named above. I consent to the assertion of paternity
by the putative father. I also declare and affirm that:
(check one)
Father
I acknowledge that I am the natural father of the child named above.
I understand that this Affidavit shall,when signed and sworn by both
parents,have the same force and effect as a judgement of the court in
establishing my paternity of the above-named child.
I was unmarried at my child's conception or birth,
I was married to someone other than the above-named father.
(See Instructions, #1 on back)
Signature of Mother
(If minor mother- parent, guardian or other adult may sign,but it is not required)
State of
County of
Sworn to and subscribed before me this
day of
,
(SEAL)
NOTARY PUBLIC
My commission expires
Signature of Father
(If minor father- parent, guardian or other adult may sign, but it is not required)
State of
County of
Sworn to and subscribed before me this
day of
,
(SEAL)
NOTARY PUBLIC
My commission expires
DHHS 1660(Revised 3/2019)
Vital Records(Review 3/2021)
INSTRUCTIONS ON REVERSE SIDE
Page 2 of 4
4/6/2023
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
N. C. VITAL RECORDS
AFFIDAVIT OF PARENTAGE FOR CHILD BORN OUT OF WEDLOCK
(Type or print all information)
We hereby affirm that
(Full Name of Child)
(Social Security Number, if Available)
who was born
, in
at
(Date of Birth)
(City, County of Birth)
(Name of Hospital or Institution--If neither,street address)
is the natural child of
(Full Name of Father)
(Social Security Number)
(Father's Address)
and
(Mother's Full Name Prior to First Marriage)
(Social Security Number)
(Mother's Address)
(County of Residence)
Affidavit signed at
(Name of Hospital, Child Support Services, Clerk of Court, Other)
INFORMATION CONCERNING THE FATHER
Race
Date of Birth
(Specify White, Black, Am. Indian, etc.)
(Month, Day, Year)
Is father of Hispanic origin?
Yes
No
If yes,
(Specify Cuban, Mexican, Puerto Rican, etc.)
Education
Birthplace
(Highest Grade Completed Elem 1-8;High 9-12; Col 13-17+)
(County, State or Foreign Country)
CERTIFICATION OF PARENTS
I acknowledge that I have received and understand the oral instructions and the information on the back of this form that explains the
purpose and consequences of signing this document, including possible requirements to pay child support.
Mother
I am the natural mother and the man named above is the natural father
of the child named above. I consent to the assertion of paternity
by the putative father. I also declare and affirm that:
(check one)
Father
I acknowledge that I am the natural father of the child named above.
I understand that this Affidavit shall,when signed and sworn by both
parents,have the same force and effect as a judgement of the court in
establishing my paternity of the above-named child.
I was unmarried at my child's conception or birth,
I was married to someone other than the above-named father.
(See Instructions, #1 on back)
Signature of Mother
(If minor mother- parent, guardian or other adult may sign,but it is not required)
State of
County of
Sworn to and subscribed before me this
day of
,
(SEAL)
NOTARY PUBLIC
My commission expires
Signature of Father
(If minor father- parent, guardian or other adult may sign, but it is not required)
State of
County of
Sworn to and subscribed before me this
day of
,
(SEAL)
NOTARY PUBLIC
My commission expires
DHHS 1660(Revised 3/2019)
Vital Records(Review 3/2021)
PARENT'S COPY
INSTRUCTIONS ON REVERSE SIDE
Page 3 of 4
4/6/2023
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
N. C. VITAL RECORDS
AFFIDAVIT OF PARENTAGE FOR CHILD BORN OUT OF WEDLOCK
(Type or print all information)
We hereby affirm that
(Full Name of Child)
(Social Security Number, if Available)
who was born
, in
at
(Date of Birth)
(City, County of Birth)
(Name of Hospital or Institution--If neither,street address)
is the natural child of
(Full Name of Father)
(Social Security Number)
(Father's Address)
and
(Mother's Full Name Prior to First Marriage)
(Social Security Number)
(Mother's Address)
(County of Residence)
Affidavit signed at
(Name of Hospital, Child Support Services, Clerk of Court, Other)
INFORMATION CONCERNING THE FATHER
Race
Date of Birth
(Specify White, Black, Am. Indian, etc.)
(Month, Day, Year)
Is father of Hispanic origin?
Yes
No
If yes,
(Specify Cuban, Mexican, Puerto Rican, etc.)
Education
Birthplace
(Highest Grade Completed Elem 1-8;High 9-12; Col 13-17+)
(County, State or Foreign Country)
CERTIFICATION OF PARENTS
I acknowledge that I have received and understand the oral instructions and the information on the back of this form that explains the
purpose and consequences of signing this document, including possible requirements to pay child support.
Mother
I am the natural mother and the man named above is the natural father
of the child named above. I consent to the assertion of paternity
by the putative father. I also declare and affirm that:
(check one)
Father
I acknowledge that I am the natural father of the child named above.
I understand that this Affidavit shall,when signed and sworn by both
parents,have the same force and effect as a judgement of the court in
establishing my paternity of the above-named child.
I was unmarried at my child's conception or birth,
I was married to someone other than the above-named father.
(See Instructions, #1 on back)
Signature of Mother
(If minor mother- parent, guardian or other adult may sign,but it is not required)
State of
County of
Sworn to and subscribed before me this
day of
,
(SEAL)
NOTARY PUBLIC
My commission expires
Signature of Father
(If minor father- parent, guardian or other adult may sign, but it is not required)
State of
County of
Sworn to and subscribed before me this
day of
,
(SEAL)
NOTARY PUBLIC
My commission expires
DHHS 1660(Revised 3/2019)
Vital Records(Review 3/2021)
PARENT'S COPY
INSTRUCTIONS ON REVERSE SIDE
Page 4 of 4
4/6/2023
1
If mother was married to someone other than the father named on this Affidavit
at the time of conception or birth
or
between conception and birth
of a child, the name of the father identified on this form will not be entered on the
birth certificate. Per N.C. General Statute 130A-101(e), the husband
must
be entered as the father on the birth
certificate unless paternity has been otherwise determined by a court of competent jurisdiction.
2
All information for the child, mother, and father must be completed on the front of this form. The information on
Effect of Signing
(1)
and
Rights and Responsibilities
(2)
below must be explained to the mother and father. The
Affidavit must be signed by each parent in the presence of a notary public, clerk of court, or military officer
authorized to administer oaths. The mother and father must be given a copy of the completed Affidavit.
3
When completed at birth, this Affidavit must be filed with the birth certificate. Under no circumstances will the birth
certificate be delayed in order to complete the Affidavit. When completed and filed at a later date, the agency
completing the Affidavit will file it with N.C. Vital Records.
(1)
Effect of Signing the Affidavit of Parentage
Upon signing this form, the declaring father's name will be listed on the birth certificate, except as noted in Instruction #1
above. He will be declared to be the natural father of the child. This admission of paternity may be retracted by either party
within 60 days of signing by filing a request with the court. The father's name may then be removed from the birth record
if there has been no administrative or judicial proceeding relating to paternity or support for this child. After 60 days, the
father's name may not be removed from these documents except by order of the court.
(2)
Rights and Responsibilities of Parents
You have the right to declare paternity by signing this document or you may choose to request paternity testing, consult an
attorney, contact Child Support Enforcement, or have a court determine paternity. A minor has the right to sign the
Affidavit with or without the signature of an adult. You, the father and mother, have a right to know your child, the right to
seek custody or visitation, as well as the responsibility to support your child. Parental rights of a parent may not be
terminated without notice to both parents.
clerk of court in the county where the father or child resides.
The execution and filing of this Affidavit with the registrar does not affect inheritance rights unless it is also filed with the
INSTRUCTIONS
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
N. C. VITAL RECORDS
AFFIDAVIT OF PARENTAGE FOR CHILD BORN OUT OF WEDLOCK
