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PATERNITY ACKNOWLEDGMENT STATE OF GEORGIA (Columbus Consolidated Government)

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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.
Mother’s Signature Father’s Signature
Acknowledged to be true and correct before me on Acknowledged to be true and correct before me on
this
day of , 20 . this day of , 20 .
Notary Public
Notary Public
My term expires on , 20
Identification presented by Mother
My term expires on
, 20
Identification
presented by Father
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.
Mother’s Signature Father’s Signature
Acknowledged to be true and correct before me on Acknowledged to be true and correct before me on
this
day of , 20 . this day of , 20 .
Notary Public Notary Public
My term expires on
, 20
Identification presented by Mother
My term expires on , 20
Identification
presented by Father
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
.
Form 3940 (Rev.
6-09)
P
urp
ose
T
he
Paternity Acknowledgment
(PA)
is a
document
which has two main
purposes
.
I
t
is used to add a father to a
child
’
s
birth
r
e
-
c
or
d
,
and it can also be used in furtherance of efforts to legitimate the relationship
between
the father and the
child
.
Restric
tions
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
an
y
other reason, there is another father listed on this
child
’
s
birth
c
er
tifica
t
e
.
If
the mother was married during this time
fr
ame
,
or if
another father is listed on the birth
r
ec
or
d
,
court action
will
be necessary to establish
pa
t
ernit
y
,
amend the birth
r
ec
or
d
,
and
establish
leg
itimation.
Paternity
Acknowledgment
S
ec
tion
Once filed with the State
Office
of
Vital
R
ec
or
ds
,
the
PA
helps establish the father and child
r
ela
tionship
.
I
t
is a voluntary
ag
r
ee
-
ment
between
the mother and the biological father to add the
fa
ther
’
s
name to the birth
r
ec
or
d
.
T
he
child
’
s
name can also
be
changed
if
agreed upon by both mother and
fa
ther
.
Acknowledgment
of
L
egitima
tion
S
ec
tion
This
section of the
document
is a voluntary declaration that the mother and biological father consent and agree that the
r
elation-
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
.
I
t
may also assist the child to receive social security benefits
fr
om
the
fa
ther
,
if
needed
.
While
this
acknowledgment
does not establish any right of visitation or
cust
ody
,
the form assists the father
t
o
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.
R
escission
of
this
document
will
rescind both the
PA
Section and the
A
ck
no
wledgemen
t
of
L
eg
itima
tion
Section. Please be advised that the
rescission
will
not remove the father from the birth certificate.
Y
ou
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
fac
t
,
with the burden of proof on the person challenging the ack
no
wledg
men
t
.
R
igh
ts
and
Resp
onsibilities
1. Signing the
PA
is strictly
v
olun
tar
y
.
2.
T
he
mother should not sign the
PA
unless she is confident that the father signing is the biological father of this
child
.
3.
T
he
father should not sign the
PA
unless he is confident that he is the biological father of this
child
.
4.
By
signing this
documen
t
,
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 fac
t
.
5. Signing the
A
ck
no
wledgemen
t
of
L
eg
itima
tion
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-
edg
men
t
.
7.
Any
change made to the birth record in the future regarding the
child
’
s
name
,
mother
’
s
name
,
or
fa
ther
’
s
name
will
require
a
court
or
der
.
Filing
I
nstr
uc
tions
T
he
PA,
once
completed
and signed in the presence of a notary
public
,
will
be forwarded to the State
Office
of
Vital
R
ec
or
ds
where
it
will
be entered into the State Putative Father
Registry
and considered a
Vital
R
ec
or
d
.
If
both parents do not sign a
PA
before leav
ing
the hospital or birthing
facility,
only the
mother
’
s
name and
child
’
s
name
will
be entered on the birth
c
er
tifica
t
e
.
T
he
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
c
op
y
of the
PA
can be
requested
by the parents from the State
Vital
R
ec
or
ds
Office
for a $10
fee. Mail
the request to: Georgia
V
ital
R
ec
or
ds
,
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
offic
e
.
Form 3940 (Rev.
6
-0
9
)
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PATERNITY ACKNOWLEDGMENT STATE OF GEORGIA (Columbus Consolidated Government)

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Completed 8 April 2022

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