STATE OF NEW JERSEY

For Official Use Only:

Father on Birth Certificate?

Yes / No

Registrar

CERTIFICATE OF PARENTAGE

THIS IS A LEGAL DOCUMENT. PLEASE PRINT OR TYPE IN BLACK OR BLUE INK

Name of child as it appears on the birth certificate:

______________________________________|_____________________|_________________________________________________|_________________

First Middle Last Sex (M/F)

who was born in ____________________________|______________/____________on ________________________________________|______|_______

Birthing Facility City/Town State (Date of Birth) Month - spelled out Day Year

MOTHER

Name______________________________|___________________________|__________________________________|_____________________________

First Middle Last Maiden

Residence______________________________________|_________________________|______|________ Home Phone # __________________________

No. & Street Name City State Zip

Place of Birth_______________________________________|______________|_____________________ Date of Birth __________|________|_________

City or Town State Country Month Day Year

Social Security # __ __ __ - __ __ - __ __ __ __ Medical Insurance (Co. & Policy #): _______________________________________________________

Employer ______________________________|__________________________________ Occupation __________________________________________

Name Address

Is/Was Mother Married at Time of Birth? (Circle One) Yes / No Was Mother Married at Time of Conception? (Circle One) Yes / No

Informant ______________________________________________________

I understand and consent to the acknowledgment of paternity and that the man named below is the only possible father of the child named above. I have read

and have had read to me my legal rights and obligations resulting from acknowledging paternity, and I understand the information on both sides of this

form. I certify the above information is true.

______________________________________________________ Date signed:________| _____| _____ Signed in hospital? Yes / No

Signature of Mother Month Day Year (Circle one)

State of New Jersey, County of ___________________________________. The above-named _________________________________________________

signed and affirmed before me this the _____________________day of ___________________________, 20______.

Notary Public/Witness:__________________________________ My Commission Expires:__________________________

FATHER

Name__________________________|_________________________|____________________________________________|_________________________

First Middle Last Home Phone #

Residence______________________________|_______________________|_______ |_________________ Social Security #__ __ __ - __ __ - __ __ __ __

No. & Street Name City State Zip

Place of Birth__________________________________________|_____________|_____________________ Date of Birth ___________|______|________

City or Town State Country Month Day Year

Medical Insurance (Co. and Policy #) _______________________________________________ Occupation _____________________________________

Employer _______________________________|___________________________________ Informant __________________________________________

Name Address

I certify and acknowledge that I am the natural father of the child named above. I have read and have had read to me my legal rights and obligations

resulting from acknowledging paternity, and I understand the information on both sides of this form. By signing this form I am consenting to have my

information added to the child’s birth certificate. I certify the above information is true.

______________________________________________________ Date Signed: __________| _____| ________ Signed in hospital? Yes / No

Signature of Father Month Day Year (Circle One)

State of New Jersey, County of ____________________________________. The above named_________________________________________________

signed and affirmed before me this the _____________________day of __________________________, 20_______.

Notary Public/Witness:__________________________________ My Commission Expires:__________________________

This Certificate of Parentage must be filed with the State or county child support office of the local registrar’s office in the community where the

child was born. If you have questions about filing this Certificate call 1-800-POP-6607.

WHAT DOES IT MEAN IF YOU SIGN THIS FORM?

By signing this Certificate of Parentage you are legally establishing your child's paternity. Paternity means fatherhood. For

parents who are not married to each other, paternity may be established legally only by signing this form or by going to court.

Parents who are married to each other do not need to sign this form because their child's paternity is already established.

Signing the form is voluntary. However, since signing this form has legal consequences, you may want to consult an attorney

before you sign.

Paternity is legally established on the date both parents sign this form. If you want to have a blood or genetic test to verify

paternity, do not sign this form until you have received the results of the test. Once signed by both parents and witnessed or

notarized, this form will have the same binding effect as a court judgment of paternity.

This form allows a parent to seek a child support order without further court proceedings to establish paternity. This form may

be filed in court and serve as the basis for orders of custody or visitation.

This form is not a public record. It will only be available to the parents and child named on this form, the child's legal guardian

or legal representative, or government officials in the conduct of their official duties.

WHAT ARE YOUR RIGHTS AND RESPONSIBILITIES AS PARENTS?

Both parents are required by law to support their child from birth. If your child does not live with you, you may be ordered by

the court to pay child support until the child's eighteenth birthday, or beyond in some circumstances.

A parent who does not live with the child may have the right to visit and establish a relationship with the child as you both agree

or as ordered by the court.

HOW WILL YOUR CHILD BENEFIT IF YOU SIGN THIS FORM?

Every child has the right to know his or her mother and father and benefit from a relationship with both parents. Your child will

have two legal parents. It will be easier for your child to learn the medical histories of both parents and to benefit from

healthcare coverage available to you.

Your child has a right to financial support from both of you until age eighteen, or beyond in some circumstances. It will be

easier for your child to receive benefits such as dependent or survivor's benefits from the Veteran's Administration or from the

Social Security Administration.

It will be easier for your child to inherit through you.

WHAT IF I CHANGE MY MIND?

This Certificate of Parentage can be rescinded at any time within 60 days of the date signed if both parties agree to rescind

by filing a Recision of Certificate of Parentage with the Bureau of Vital Records.

If only one person wants to rescind within the 60 day timeframe, an action must be filed with the court.

If the Certificate of Parentage is rescinded within the 60 day time frame, the father's name and information will be removed

from your child's birth certificate. Please note, however, that either party can later bring a court action to establish paternity.

After this 60 day period, parents can challenge the Certificate of Parentage in court only on the basis of fraud, duress, or

material mistake of fact. The parent attempting to rescind must provide proof of fraud, duress, or material mistake of fact.