Form Hfs 3416D – Fill Out and Use This PDF

Illinois Denial of Paternity

Instructions: Do not cross out words or make corrections or your form will be rejected. If you make a mistake, complete and print a new form. Print 4 copies, sign each copy and have your witness sign and complete each copy. See additional instructions on the 2nd page of this form.

Read carefully and complete all requested information before signing this form. Call the Child Support Customer Service Call Center at 1-800-447-4278 if you have questions. Questions about the birth certificate must be directed to the Illinois Department of Public Health, Division of Vital Records,

at www.idph.state.il.us/vitalrecords or 217-782-6554.

Date of Marriage

By signing, I:

1.Understand that this is a legal document. I understand that the Denial of Paternity (hereafter called Denial) is completed when the mother is or was married at the time of conception and/or upon the birth of the child and the husband/ex-husband is not the biological father.

2.Understand that the mother and the husband/ex-husband must sign a Denial and that the mother and biological father must sign the Voluntary Acknowledgment of Paternity (hereafter called VAP) to establish legal paternity and place the biological father's name on the child's birth certificate.

3.Understand that if the mother and the husband/ex-husband do not sign the Denial and the mother and biological father do not sign the VAP, the husband/ex-husband, by law, is presumed to be the father and his name must be placed on the child's birth certificate.

4.Understand that when the mother and the husband/ex-husband sign the Denial and the mother and biological father sign the VAP, the biological father becomes the legal father of the child for all purposes. The husband/ex-husband waives his legal rights and responsibilities to the child.

5.Understand that either the mother or biological father of the child may withdraw the action of signing the VAP by signing a Rescission of Voluntary Acknowledgment of Paternity (hereafter called Rescission). The Rescission must be signed and received by the Department within 60 days of signing the VAP or the date of a proceeding relating to the child, whichever occurs earlier. Upon Department verification of the Rescission, the husband/ex-husband is legally responsible for support of the child.

6.Have read the instructions on the reverse side of this form and understand my rights and responsibilities created and waived by signing this form.

I UNDERSTAND THAT I CAN REQUEST A GENETIC TEST REGARDING THE CHILD'S PATERNITY. BY SIGNING THIS FORM I GIVE UP MY RIGHT TO A GENETIC TEST.

Husband/Ex-husband's Signature

Mother's Signature

Print Name of Husband/Ex-husband

Print Name of Mother

Witness' Signature

Witness' Signature

Print Name of Witness

Print Name of Witness

Witness Address

Witness Address

Witness' Telephone #

Witness' Telephone #

Date Parties Signed

Date Parties Signed

Send one copy to HFS/ACU, 110 W Lawrence, Springfield, IL 62704 if signed in hospital. Send two copies to HFS if signed outside hospital.

One Copy is for the Hospital if signed in hospital				One Copy is for the Mother				One Copy is for the Husband/Ex-husband
For Official Use Only
	Case #		Docket #			CP RIN		NCP RIN		Child RIN

HFS 3416D INTERNET (R-7-10))

Instructions for Completing the Illinois Denial of Paternity

PURPOSE: The Denial of Paternity (hereafter called Denial), is completed when the mother of the child is or was married at the time of conception and/or upon the birth of the child, the husband/ex-husband is not the biological father and the biological father acknowledges paternity of the child by completing and signing the Voluntary Acknowledgment of Paternity (hereafter called VAP), with the mother of the child.

PLEASE READ ALL PARTS OF THIS FORM, INCLUDING THE INFORMATION REGARDING YOUR RIGHTS AND RESPONSIBILITIES BEFORE COMPLETING THIS FORM.

1.The Denial may not be signed before the child is born.

2.Each person must sign and date all forms in front of a witness. A witness must be an adult age eighteen or older but cannot be the parents or the child named on the Denial/VAP.

3.If you are completing the Denial and VAP at the hospital when your baby is born, hospital staff will add the biological father's name to the birth certificate.

4.You may complete the Denial and VAP after you leave the hospital, however, if the Denial and VAP are not completed at the hospital, the parents must sign and date the form(s) in front of an adult witness.

5.You may complete the Denial and VAP for a child born in another state when the biological father was not married to the mother of the child.

6.Send two copies to the Department's:

Administrative Coordination Unit (ACU)

110 West Lawrence Avenue

Springfield, Illinois 62704

To ensure that the biological father's name is placed on the child's birth certificate, the ACU will then send the completed Denial and VAP to either the:

1.Illinois Department of Public Health, Division of Vital Records (for Illinois births), or

2.Vital Records Office in affected state (for out of state births)

NOTE: Forms that contain errors will be rejected. As a result, paternity is not established and the biological father's name will not be placed on the birth certificate.

FOR MORE INFORMATION about completing the Denial and VAP, read the flyer "Two Parents...Give Your Child HOPE". You may obtain the flyer by asking hospital staff, state and local registrars, county clerks, Department of Human Services offices or Child Support Services offices. You will also be given a child support services application (HFS 1283) if you are not currently receiving public assistance.

Spanish versions are available upon request and on the Department's website (www.ChildSupportIllinois.com), but may be used for translation purposes only. The Spanish versions are not acceptable as legal documents. Only the English version of the documents may be signed and witnessed.

SI LAS PIDE, TENEMOS VERSIONES DE ESTE FORMULARIO EN ESPAÑOL Y TAMBIÉN PUEDE CONSEGUIRLAS POR INTERNET EN EL SITIO DEL DEPARTAMENTO EN (www.ChildSupportIllinois.com), PERO SÓLO SE PUEDEN USAR PARA PROPÓSITOS DE TRADUCCIÓN. LA VERSIÓN EN ESPAÑOL NO ES UN DOCUMENTO LEGAL ACEPTABLE. SÓLO LA VERSIÓN EN INGLÉS DEL DOCUMENTO SE PUEDE FIRMAR Y ATESTIGUAR.

If you have any questions relating to the child's birth certificate, please contact the Department of Public Health's Division of Vital Records at www.idph.state.il.us/vitalrecords or 217-782-6554.

If you have any questions relating to completing this form, please call the Child Support Customer Service Call Center at 1-800-447-4278.

HFS 3416D INTERNET (R-7-10))