Fillable FORM 3940 (REVISED 03/2018): PATERNITY ACKNOWLEDGEMENT (State of Georgia)

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FORM 3940 (REVISED 03/2018): PATERNITY ACKNOWLEDGEMENT (State of Georgia)

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PATERNITY ACKNOWLEDGEMENT
FORM 3940 (REVISED 03/2018)
PLEASE ADDRESS ALL CORRESPONDENCE TO THE ADDRESS BELOW.
STATE OFFICE OF VITAL RECORDS1680 PHOENIX BLVD. SUITE 100, ATLANTA, GA 30349 PHONE 404.679.4702
Please Note: There is a $10.00 processing fee for this form, if the request is submitted after one year. If this request is being mailed, please
forward this completed form with a U.S. Money Order or certified check for the correct amount made payable to the State Office of Vital
Records. A valid copy of your Photo ID must accompany this request. Please do not send cash by mail.
PLEASE PRINT OR TYPE ALL INFORMATION LEGIBLY AND CORRECTLY BELOW AND SEE INSTRUCTIONS ON BACK.
Section 1: CHILD/PARENT’S INFORMATION
STATE FILE NUMBER
FACILITY
Please Note: Do not use this form if the mother was married to anyone within 10 months prior to the birth of this child or if,
for any reason, there is another father of this child listed on the child’s birth certificate.
FATHER’S FIRST NAME AT BIRTH
FATHER’S MIDDLE NAME AT BIRTH
FATHER’S LEGAL LAST NAME
GENERATION (JR., II, III, ETC.)
The father acknowledges that he is the biological (natural) father of the child born to
MOTHER’S FIRST NAME AT BIRTH
MOTHER’S LAST NAME AT BIRTH
We are requesting that the name of the biological father be placed on the birth certificate and that the child be named:
CHILD’S FIRST NAME
CHILD’S MIDDLE NAME
CHILD’S LAST NAME
GENERATION (JR., II, III, ETC.)
CHILD’S SEX (FEMALE OR MALE)
CHILD’S DATE OF BIRTH & COUNTY
IDENTIFY IF THERE WAS A FETAL DEATH OR STILLBIRTH
Section 2: PARENT’S INFORMATION
MOTHER’S INFORMATION: ADDRESS (STREET NAME & NUMBER, CITY, STATE, & ZIP CODE)
DATE & PLACE OF BIRTH (STATE IN U.S. OR COUNTRY IF NOT U.S.)
SOCIAL SECURITY NUMBER
EMPLOYER
ADDRESS (STREET NAME & NUMBER, CITY, STATE, & ZIP CODE)
FATHER’S INFORMATION: ADDRESS (STREET NAME & NUMBER, CITY, STATE, & ZIP CODE)
DATE & PLACE OF BIRTH (STATE IN U.S. OR COUNTRY IF NOT U.S.)
SOCIAL SECURITY NUMBER
EMPLOYER
ADDRESS (STREET NAME & NUMBER, CITY, STATE, & ZIP CODE)
Section 3: NOTARY PUBLIC
I understand that either parent may withdraw this paternity acknowledgement, 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.
Note: By signing this document, you are stating that you 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.
MOTHER’S SIGNATURE
FATHER’S SIGNATURE
PARENT’S SIGNATURE (IF MOTHER IS A MINOR UNDER AGE 18, A PARENT MUST ALSO SIGN.)
PARENT’S SIGNATURE (IF FATHER IS A MINOR UNDER AGE 18, A PARENT MUST ALSO SIGN.)
ACKNOWLEDGED TO BE TRUE BEFORE ME ON (NOTARY’S SIGNATURE & DATE):
ACKNOWLEDGED TO BE TRUE BEFORE ME ON (NOTARY’S SIGNATURE & DATE):
MY TERM EXPIRES ON (DATE):
MY TERM EXPIRES ON (DATE):
IDENTIFICATION TYPE & NO. PRESENTED BY MOTHER
IDENTIFICATION TYPE & NO. PRESENTED BY FATHER
PLEASE PLACE THE NOTARY SEAL BELOW.
PLEASE PLACE THE NOTARY SEAL BELOW.
PATERNITY ACKNOWLEDGEMENT
FORM 3940 (REVISED 03/2018)
PLEASE ADDRESS ALL CORRESPONDENCE TO THE ADDRESS BELOW.
STATE OFFICE OF VITAL RECORDS1680 PHOENIX BLVD. SUITE 100, ATLANTA, GA 30349 PHONE 404.679.4702
PURPOSE
The Paternity Acknowledgement (PA) is a document which is used to add a biological (natural) father to a child’s birth record.
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 ACKNOWLEDGEMENT
Once filed with the State Office of Vital Records, the PA helps establish the father and child relationship. It is a voluntary
agreement 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 within the first year of birth if agreed upon by both the mother and father.
MINOR PARENT
An unwed parent under the age of 18 may sign the PA form without parental consent if:
1. He/she is on active duty with the military.
2. Emancipation has been granted by a court order.
RESCISSION
Either the mother or biological father has 60 days from the date of his/her signature to request to rescind this PA. 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 acknowledgement.
RIGHTS & 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. Any change made to the birth record in the future regarding the child’s information, mother’s information, or father’s
information will require a court order.
6. The PA must be notarized and filed with the State Office of Vital Records within 30 days of execution.
7. Each parent is entitled to a copy of the PA after it has been signed and notarized.
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 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. For information on how to rescind a signed PA, contact either the State Office or a local County Vital Records Office.
Notice: Establishment of paternity does not entitle the father to custody, visitation or rights of inheritance from or to a child.
Those rights must be established by the filing of a petition for legitimation with the court.
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FORM 3940 (REVISED 032018): PATERNITY ACKNOWLEDGEMENT (State of Georgia)

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Completed 9 September 2021

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