Fillable APPLICATION FOR NOTICE OF INTENT TO CLAIM PATERNITY (Texas Secretary of State)

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APPLICATION FOR NOTICE OF INTENT TO CLAIM PATERNITY (Texas Secretary of State)

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VS – 130 (1/22)
APPLICATION FOR NOTICE OF INTENT TO CLAIM PATERNITY
PLEASE PRINT CLEARLY.
• COMPLETE PARTS 1, 2, & 3.
• Your name, date of birth, and address are required.
• The child’s name, date of birth, place of birth, and mother’s maiden name are very critical to linking the notice of
intent to claim paternity with an actual child. The more complete the information you provide, the more effective the
paternity registry can be
.
•
Mail this application to the Paternity Registry address listed on the next page.
SEE INFORMATION ON BACK. The information provided on the back is not designed to be legal advice. Questions concerning
paternity, presumptions of paternity, or rights and responsibilities of a parent should be directed to an attorney.
Part 1: MAN’S INFORMATION TO BE INCLUDED IN PATERNITY REGISTRY
Your Name (First, Middle, Last Name):
Date of Birth (MM/DD/YYYY):
Street Address:
City:
State:
Zip Code:
Driver’s License Number:
Driver’s License State:
☐ I authorize mailing to the address below instead of my mailing address listed above.
Name:
Address to Send to if different than noted above:
City:
State:
Zip Code:
Part 2: CHILD’S INFORMATION
FULL NAME:
First
Middle
Last
Date of Birth (MM/DD/YYYY):
Expected Date of Birth (MM/DD/YYYY):
Sex:
BIRTHPLACE:
Hospital Name
City
County
State
TEXAS
Part 3: MOTHER’S INFORMATION
FULL NAME:
First
Middle
Last
Maiden (Before First Marriage)
Date of Birth (MM/DD/YYYY):
Social Security Number:
Driver’s License Number:
Driver’s License State:
Last
known
address:
Street Address:
City:
County:
Zip Code:
WARNING: IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY MAKING A FALSE
STATEMENT ON THIS FORM OR SIGNING A FORM WHICH CONTAINS A FALSE STATEMENT IS 2 TO 10 YEARS IMPRISONMENT AND A FINE
OF UP TO $10.000. (HEALTH AND SAFETY CODE, CHAPTER 195, SEC. 195.003.)
READ & SIGN (Applications without signatures will NOT be accepted for processing)
I declare under penalty of perjury that I am the father of the above child. I understand my name and
information will be included in the paternity registry maintained by Vital Statistics, Texas Department of State
Health Services. I further understand that:
• Placing this form on file with Vital Statistics, Texas Department of State Health Services, entitles me to
notice of proceeding for adoption of the child named above or for termination of my parental rights;
• Placing this form on file does not establish legal paternity of the child and does not begin the process of
establishing legal paternity of the child;
• The information contained in this form may be used in a legal proceeding to establish paternity of the
child.
Signature of Man __________________________ Date Signed (MM/DD/YYYY) _____/_____/_________
OFFICE USE ONLY
ACTUAL NAME OF CHILD: __________________________________
DOB: _______________ STATE FILE #________________________
☐ DENIAL RECEIVED ☐ NOTICE SENT TO MOTHER
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VS – 130 (1/22)
APPLICATION FOR NOTICE OF INTENT TO CLAIM PATERNITY
BACKGROUND AND PURPOSE
HB1091, 75th Legislative session amended Section 160, Texas Family Code, creating a Paternity Registry in the Vital
Statistics, Texas Department of State Health Services. The purpose of the registry is to permit a man alleging to be the
biological father of a child to assert his parentage, independent of the mother, and preserve his right as a parent. This
registry also may expedite adoptions of children whose biological fathers are unwilling to assume responsibility of their child.
A man is not required to register with the paternity registry if he is presumed to be the biological father.
Presumptions under the Family Code include:
1. Man and biological mother are married to each other and the child was born during wedlock or within 300 days
after the marriage was terminated;
2. Before the birth of the child, man and biological mother attempted to marry in compliance with law but the
marriage is or was void and the child was born within 300 days of when the attempted marriage terminated;
3. After the birth, the man and biological mother married or attempted to marry, he voluntarily asserted his
paternity of the child, and:
a. The assertion is in a record filed with the Texas Vital Statistics;
b. He is voluntarily named as the child’s father on the child’s birth certificate; or
c. Is obligated to support the child by written promise or court order.
INFORMATION
• This notice of intent to claim paternity must be filed before the birth of the child or not later than the 31st day
after the date of birth of the child.
• The Texas Vital Statistics will send a copy of the notice of the registration to a mother named on a notice of intent
to claim paternity form.
• The information in this form is admissible in court proceedings.
• Service to assist in establishing paternity can be obtained through the Office of the Attorney General,
Child Support Division, or by hiring an attorney.
• If the conception or birth of the child occurred in another state, a man should also register with the
registry of paternity in that other state.
• Information on registries in other states is available from the Texas Vital Statistics.
• A man who fails to file a notice of intent to claim paternity by the 31st day after the date of birth of the child may
not assert an interest in the child other than by filling a suit to establish paternity before the termination of a
man’s paternal rights.
• A man who files a notice of intent to claim paternity must promptly notify the registry in writing of any change in
information including a change of address.
• A man may rescind the notice of intent at any time by sending the registry a written statement signed
and witnessed or notarized either stating to the best of the man’s knowledge and belief that he is not
the father or that a court has adjudicated another person to be the father of the child.
• The registry address:
DSHS-VSS Paternity Registry MC 1966
P.O. Box 149347
Austin, Texas 78714-9347
Toll Free #: (888) 963-7111
https://www.dshs.state.tx.us/vs/paternity/registry.aspx
• Information in the registry is confidential and may only be released to certain individuals or entities.
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APPLICATION FOR NOTICE OF INTENT TO CLAIM PATERNITY (Texas Secretary of State)

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Completed 19 May 2022

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