Form 3012 – Fill Out and Use This PDF

PATERNITY ACKNOWLEDGMENT – STATE OF GEORGIA

(Print or type all information in black or blue permanent ink. This form may be copied.)

State File Number:		Facility:

PLEASE NOTE: This form cannot be completed if the mother was married to anyone within the 10 months prior to the birth of this child or if, for any other reason, there is another father of this child listed on the child’s birth certificate.

is the biological (natural) father of the child born to

FATHER’S

| First Name

Middle

Last / Generation (Jr., III, etc)

on the

day of

, 20

in

MOTHER’S | First Name

Middle

Last

Maiden Name

County, Georgia. We are requesting to have the name of the biological father placed on the birth certificate and

that the child be named:

CHILD’S

| First Name

Middle

Last Name /Generation

Mother’s Information:

Address

Number and Street Name

City

State

Zip Code

Date of Birth:

Social Security Number

Employer

Employer’s Address

Father’s Information:

Address

Number and Street Name

City

State

Zip Code

Date of Birth:

State of Birth

Social Security Number

Employer

Employer’s Address

I understand that either parent may withdraw this paternity acknowledgment, without penalty, within 60 days from the date of his/her signature. I have been informed of my rights and responsibilities as explained on the reverse side of this form.

ACKNOWLEDGMENT OF LEGITIMATION

We, the mother and biological father, voluntarily consent and agree that the relationship between the child and the father shall be considered legitimate for all purposes under law pursuant to O.C.G.A. §19-7-21.1. Note: This section does not apply if the child is over one year of age at the time this document is signed.

NOTE: By signing this document, you are stating that you have read and understood all of its provisions, including those printed on the reverse side of this document and that the facts stated on this document are true. Pursuant to O.C.G.A. §31-10-31, anyone making a false statement on this document may go to prison for up to five years and fined up to $10,000. Photo ID is required of all individuals signing this document.

Purpose

The Paternity Acknowledgment (PA) is a document which has two main purposes. It is used to add a father to a child’s birth re- cord, and it can also be used in furtherance of efforts to legitimate the relationship between the father and the child.

Restrictions

A PA cannot be used if the mother of the child was married to anyone within 10 months prior to the birth of this child or, if for any other reason, there is another father listed on this child’s birth certificate. If the mother was married during this time frame, or if another father is listed on the birth record, court action will be necessary to establish paternity, amend the birth record, and establish legitimation.

Paternity Acknowledgment Section

Once filed with the State Office of Vital Records, the PA helps establish the father and child relationship. It is a voluntary agree- ment between the mother and the biological father to add the father’s name to the birth record. The child’s name can also be changed if agreed upon by both mother and father.

Acknowledgment of Legitimation Section

This section of the document is a voluntary declaration that the mother and biological father consent and agree that the relation- ship between the child and father shall be considered legitimate for all purposes under the law according to O.C.G.A. §19-7-21.1. This could assist the father and child to inherit from each other. It may also assist the child to receive social security benefits from the father, if needed. While this acknowledgment does not establish any right of visitation or custody, the form assists the father to have standing in court regarding visitation and custody issues. Note: This section does not apply if the child is over one

year of age at the time this document is signed.

Rescission

Either the mother or biological father has 60 days from the date of his/her signature to request to rescind this PA. Rescission of this document will rescind both the PA Section and the Acknowledgement of Legitimation Section. Please be advised that the rescission will not remove the father from the birth certificate. You must obtain a court order to remove the father from the birth certificate or make further amendments to the certificate. After the 60 day rescission period has ended, this signed document may constitute a legal determination of paternity and can only be challenged in a court of law on the basis of fraud, duress, or material mistake of fact, with the burden of proof on the person challenging the acknowledgment.

Rights and Responsibilities

1.Signing the PA is strictly voluntary.

2. The mother should not sign the PA unless she is confident that the father signing is the biological father of this child.

3.The father should not sign the PA unless he is confident that he is the biological father of this child.

4.By signing this document, it will be presumed by law that the male signer is the biological father of this child, and the child’s birth certificate will reflect this fact.

5.Signing the Acknowledgement of Legitimation portion of this document signifies an agreement to voluntarily legitimate the relationship between the child and the acknowledged father for all purposes under the law according to O.C.G.A. §19-7-21.1.

6.Either the mother or father who signs this document has 60 days from the date of signing to rescind or cancel this acknowl- edgment.

7.Any change made to the birth record in the future regarding the child’s name, mother’s name, or father’s name will require a court order.

Filing Instructions

The PA, once completed and signed in the presence of a notary public, will be forwarded to the State Office of Vital Records where it will be entered into the State Putative Father Registry and considered a Vital Record. If both parents do not sign a PA before leaving the hospital or birthing facility, only the mother’s name and child’s name will be entered on the birth certificate. The PA may be signed before a notary at a later date and mailed to the to the State Office of Vital Records. Upon receipt of an acceptable PA form, the certificate of birth will be amended to enter the name of the father and change the child's name, if requested. A certified copy of the PA can be requested by the parents from the State Vital Records Office for a $10 fee. Mail the request to: Georgia Vital Records, 2600 Skyland Drive, Atlanta, GA 30319. For information on how to rescind a signed PA, contact either the state or a local county vital records office.

Form 3940 (Rev. 6-09)