New York Codes, Rules and Regulations › Title 22 - JUDICIARY › Subtitle D - Forms › Chapter IV - Forms of the Family Court of the State of New York and Adoption Forms of the Family Court of the State of New York (cf. s205.7) › Subchapter A - Forms Authorized by Section 205.7 › Uniform Interstate Family Support Act Forms › Form UIFSA-6 - Affidavit in support of establishment of paternity

Current through Register Vol. 46, No. 28, July
					 10, 2024
F.C.A. Art. 5-B UIFSA-6
AFFIDAVIT IN SUPPORT OF ESTABLISHING
						PATERNITY
Petitioner [ ] IV-D Non-Public
						Assistance
[ ] IV-D Non PA Medicaid
[ ] Full Services
[ ] Medical Services Only
Respondent [ ] IV-D Public
						Assistance
[ ] IV-E Foster Care (IV-D Case)
[ ] Non-IV-D
File Stamp
Responding IV-D Case No. ________
						Initiating IV-D Case No. ____________
Responding Docket No. ________ Initiating
						Docket No. ____________
____________
A Separate Affidavit is Required for Each
						Child Needing Paternity Established.
____________
SECTION I
I,
_____________
Name (First, Middle, Last), on oath, under
						penalty of perjury depose and allege:
1. I am the [ ] natural mother of the
						child named below:
[ ] natural father
Child's Full Name (First, Middle,
									 Last)
Child's Date of Birth (Month, Date,
									 Year)
Place of Birth (City, County,
									 State)
Date Mother Got Pregnant (Month, Date,
									 Year)
Full Term Pregnancy [ ] Yes [ ] No (If No,
									 explain)
Where Mother Got Pregnant (City, County,
									 State)
2. The child was conceived as a result of
						sexual intercourse between
Name (First, Middle, Last)
and me during the time stated
						above.
3. a. A man is named as the father on the
						child's birth certificate. [ ] Yes (Attach copy) [ ] No
If Yes, the man's name and address
						are:
b. A man was married to the natural
						mother, and the child's birth occurred within a year of the end of the
						marriage. [ ] Yes [ ] No
If Yes, the man's name and address
						are:
c. A man signed an acknowledgment of
						paternity. [ ] Yes (Attach copy) [ ] No
If Yes, the man's name and address
						are:
d. A man acted as and presented himself to
						be the child's father. [ ] Yes [ ] No
If Yes, the man's name and address
						are:
e. Genetic tests were completed to
						determine the father of the child. [ ] Yes [ ] No
If Yes, attach results.
____________
Affidavit in Support of Establishing
						Paternity OMB No. 0970 - 0085 Page 1 of 3
AFFIDAVIT IN SUPPORT OF ESTABLISHING
						PATERNITY, PAGE 2
Initiating IV-D Case No.
____________
SECTION II (TO BE COMPLETED BY MOTHER
						ONLY)
1. I had sexual intercourse with another
						man (other than the man I am naming as the child's natural father) during the
						time 30 days before or 30 days after the child was conceived. [ ] Yes [ ] No.
						(If Yes, complete the following).
a. The name(s) and address(es) of the
						other man/men:
b. The other man/men are biologically
						related to the man I am naming as the child's natural father. [ ] Yes [ ] No.
						If Yes, explain the biological relationship (e.g., brother, cousin, uncle,
						etc.):
c. I do not believe the other man/men
						is/are the father because:
2. I was married at the time of this
						child's birth. [ ] Yes [ ] No. (If Yes, complete the following.)
a. Husband's name (first, middle, last)
						and last known address:
b. Explain why the husband is not the
						father of this child and attach all appropriate documents, including divorce
						decree, blood test results and prior findings of nonpaternity, if any:
3.
__________
Name (First, Middle, Last) is the father
						of this child. The following facts support my allegations of paternity:
a. We lived together.
[ ] Yes [ ] No
Dates: To Location
b. I have told welfare officials that he is the
									 father of this child.
[ ] Yes [ ] No
c. I told him that he was the father of the
									 child.
[ ] Yes [ ] No
d. He is named as the father on the birth
									 certificate.
[ ] Yes [ ] No
[ ] Certified Copy Attached
e. He admitted being the father of the
									 child.
[ ] Yes [ ] No
f. He signed an acknowledgment of
									 paternity.
[ ] Yes [ ] No
[ ] Certified Copy Attached
g. He sent cards/letters regarding the
									 pregnancy and/or about the child.
[ ] Yes [ ] No
[ ] Copies Attached
h. He was present at the birth of the
									 child.
[ ] Yes [ ] No
i. He visited the child at the hospital
									 following birth.
[ ] Yes [ ] No
j. He offered to pay for an abortion/medical
									 expenses.
[ ] Yes [ ] No
k. He paid for birth related
									 expenses.
[ ] Yes [ ] No
l. He claimed the child on tax
									 returns.
[ ] Yes [ ] No
[ ] Don't Know
m. He has provided food, clothing, gifts or
									 financial support for the child.
[ ] Yes [ ] No
If Yes, explain in Section IV
n. He lived with the child.
[ ] Yes [ ] No
If Yes, explain in Section IV
o. He visited the child.
[ ] Yes [ ] No
If Yes, explain in Section IV
p. The child resembles him. [ ] Photo
									 attached
[ ] Yes [ ] No
If Yes, explain in Section IV
q. There are witnesses to my relationship with
									 him.
[ ] Yes [ ] No
(If Yes, list names and addresses and briefly
									 describe relevant facts known by each under Section IV)
____________
Affidavit in Support of Establishing
						Paternity Page 2 of 3
AFFIDAVIT IN SUPPORT OF ESTABLISHING
						PATERNITY, PAGE 3
Initiating IV-D Case No.
____________
SECTION III (TO BE COMPLETED BY FATHER
						ONLY)
The following facts support my belief and
						statements that I am the father of this child:
a. The mother and I lived together.
[ ] Yes [ ] No
Dates: To Location
b. The mother told me that I am the father of
									 the child.
[ ] Yes [ ] No
c. I am named as the father on the birth
									 certificate.
[ ] Yes [ ] No
[ ] Certified Copy Attached
d. I signed an acknowledgment of
									 paternity.
[ ] Yes [ ] No
[ ] Certified Copy Attached
e. I was present at the birth of the
									 child.
[ ] Yes [ ] No
f. I visited the child at the hospital
									 following birth.
[ ] Yes [ ] No
g. I offered to pay for an abortion/medical
									 expenses.
[ ] Yes [ ] No
h. I paid for birth related
									 expenses.
[ ] Yes [ ] No
i. I claimed the child on tax
									 returns.
[ ] Yes [ ] No
j. I have provided food, clothing, gifts or
									 financial support for the child.
[ ] Yes [ ] No
If Yes, explain in Section IV
k. I lived with the child.
[ ] Yes [ ] No
If Yes, explain in Section IV
l. I visited the child.
[ ] Yes [ ] No
If Yes, explain in Section IV
m. The child resembles me. [ ] Photo
									 attached
[ ] Yes [ ] No
If Yes, explain in Section IV
n. There are witnesses to my relationship with
									 the child's mother.
[ ] Yes [ ] No
(If Yes, list names and addresses and briefly
									 describe relevant facts known by each under Section IV)
SECTION IV -- OTHER PERTINENT INFORMATION
						(including detailed explanations for "Yes" responses in Section II or Section
						III above)
[ ] Continued On Attached Sheet(s),
						incorporated by reference.
All of the information and facts contained
						in this AFFIDAVIT IN SUPPORT OF ESTABLISHING PATERNITY are true and correct to
						my best knowledge and belief. I agree to submit myself and, if I am the
						custodian, my child to genetic testing as may be necessary to establish
						paternity.
__________
Date
Signature
__________
Sworn to and Signed before me
Notary Public/Official and Title this
						Date, County and State
Commission Expires
____________
Affidavit in Support of Establishing
						Paternity Page 3 of 3
OMB No. 0970 - 0085
INSTRUCTIONS FOR AFFIDAVIT IN SUPPORT OF
						ESTABLISHING PATERNITY
PURPOSE OF THE FORM: This affidavit
						supplements the Uniform Support Petition to summarize evidence to establish
						paternity. A separate Affidavit in Support of Establishing Paternity is
						required for each child needing paternity establishment. This is necessary
						since the circumstances surrounding conception and birth will differ unless the
						children are twins. Reminder: A putative father may petition for paternity
						establishment under UIFSA. All appropriate information for the Affidavit in
						Support of Establishing Paternity must be completed or furnished by the parent,
						properly signed by the parent, and notarized as required.
HEADING/CAPTION: [To be completed by the
						Child Support (IV-D) Worker]
Identify the petitioner and respondent in
						the appropriate spaces.
Check the appropriate space to identify
						the type of case: IV-D Non Public Assistance; IV-D Non Public Assistance
						Medicaid (indicate whether receiving Full Services or Medical Services Only);
						IV-D Public Assistance; IV-E Foster Care; or Non IV-D. IV-D means the case is
						being worked by the State or local child support enforcement agency (i.e., IV-D
						agency). Public Assistance means the obligee's family receives IV-A cash
						payments [IV-A was formerly called Aid to Families with Dependent Children
						(AFDC) and is now called Temporary Family Assistance]. A IV-D Non Public
						Assistance Medicaid case is a case where the obligee's family receives Medicaid
						but does not receive Public Assistance (IV-A cash payments).
Under "Responding IV-D Case No." and
						"Responding Docket No.", enter appropriate case and docket numbers that the
						responding State uses to identify the case, if applicable and if known. Under
						"docket number", you may enter the docket number, cause number, or any other
						appropriate reference number.
Under "Initiating IV-D Case No." and
						"Initiating Docket No.", enter appropriate case and docket numbers which your
						IV-D agency or local tribunal has assigned to the case. Under "docket number",
						you may enter the docket number, cause number, or any other appropriate
						reference number.
SECTION I: (Information to be completed or
						furnished by parent of the child)
Enter the full name (First, Middle, Last)
						of the parent completing the affidavit.
Item 1: Check whether you (the parent) are
						the natural mother or natural father of the child.
Enter the "Child's Full Name", "Child's
						Date of Birth", and "Place of Birth".
"Date Mother Got Pregnant" - Enter the
						date or period of time when you believe the mother became pregnant (e.g.,
						4/1/89 or from 4/1/89 to 5/1/89). Be sure to include the year when providing
						date(s). Be as specific as possible, providing an individual date, multiple
						dates or a range of dates. If additional space is needed, continue in Section
						IV or on an attached separate sheet.
"Full Term Pregnancy" - Check "Yes" or
						"No" to indicate whether or not the pregnancy lasted nine months. If no,
						explain (e.g., 6 months--child born premature).
"Where Mother Got Pregnant" - List the
						City, County and State.
____________
Instructions for Affidavit in Support of
						Establishing Paternity--Page 1
Item 2: Enter the name of the child's
						other parent in the blank. This is the person with whom you (the parent
						completing the affidavit) had sexual intercourse which resulted in the child's
						conception.
Item 3a: Check "Yes" or "No" to indicate
						whether or not a man is named as the child's father on the child's birth
						certificate. If "Yes", attach a copy of the birth certificate and provide the
						man's name and address. The man may be the same man who is named as the father
						of the child in this affidavit, or he may be a different man.
Item 3b: Check "Yes" or "No" to indicate
						whether or not a man was married to the child's natural mother and the child's
						birth occurred within a year of the end of the marriage. If "Yes", provide the
						man's name and address. The man may be the same man who is named as the father
						of the child in this affidavit, or he may be a different man.
Item 3c: Check "Yes" or "No" to indicate
						whether or not a man signed an acknowledgment of paternity. If "Yes", attach a
						copy of the acknowledgment and provide the man's name and address. The man may
						be the same man who is named as the father of the child in this affidavit, or
						he may be a different man.
Item 3d: Check "Yes" or "No" to indicate
						whether or not a man acted as and presented himself to be the child's father.
						If "Yes", provide the man's name and address. the man may be the same man who
						is named as the father of the child in this affidavit, or he may be a different
						man.
Item 3e: Check "Yes" or "No" to indicate
						whether or not genetic tests (e.g., blood tests) were completed to determine
						the father of the child. If "Yes", attach the test results.
SECTION II: (To be completed by Mother
						Only)
Item 1: Check "Yes or "No" to indicate
						whether you (the mother) did or did not have sexual intercourse (sex) with
						another man or other men during the 30 days before or the 30 days after the
						child was conceived ("Date Mother Got Pregnant").
If you had sexual intercourse with another
						man or other men during this period (30 days before or 30 days after), complete
						items 1a through 1c.
Item 1a: Provide the name(s) and
						address(es) of the other man/men.
Item 1b: Check "Yes" or "No" to indicate
						whether the other man/men are biologically related to the alleged father. If
						"Yes", state the relationship (e.g., brother, cousin, etc). This may be
						relevant to genetic testing.
Item 1c: Explain why you do not believe
						the other man/men is/are the father of this child (e.g., prior exclusion by
						genetic testing).
Item 2: Check "Yes" or "No" to indicate
						whether or not you were married at the time of the child's birth. If "Yes",
						complete items 2a and 2b.
Item 2a: Provide the name and address of
						your husband (at the time of the child's birth).
Item 2b: Explain why the husband is not
						the father. Attach appropriate documents.
Item 3: Be sure to enter the name of the
						father of this child. Check the appropriate answer for each statement (a-q) to
						support the allegations of paternity against the alleged father. Remember to
						attach any necessary, relevant documentation. This includes a certified copy of
						the birth certificate with the alleged father's name on it; a certified copy of
						a paternity acknowledgment; and other documents if available (e.g., letters or
						cards from the alleged father regarding the pregnancy or the child). Note: some
						responding States may only need a regular copy of a birth certificate or
						paternity acknowledgment, rather than a certified copy.
____________
Instructions for Affidavit in Support of
						Establishing Paternity--Page 2
SECTION III: (To be completed by Father
						Only)
Reminder: A putative father may petition
						for paternity establishment under UIFSA.
Check the appropriate answer for each
						statement (a-n). Remember to attach any necessary, relevant documentation. This
						includes a certified copy of the birth certificate with your name as the
						child's father on it; a certified copy of a paternity acknowledgment; and other
						documents if available (e.g., letters or cards from the mother regarding the
						pregnancy of the child). Note: some responding States may only need a regular
						copy of the birth certificate or paternity acknowledgment, rather than a
						certified copy.
SECTION IV: Provide any additional
						information not already covered which might be helpful in establishing
						paternity. One example would be the alleged father's attendance in a child
						birth class with the mother.
If you are the mother, provide details to
						"Yes" answers to item 3, statements m through q in Section II.
(m) Describe any food, clothing, gifts, or
						financial support the alleged father has provided for the child.
(n) Describe where and when the alleged
						father lived with the child.
(o) Provide dates and circumstances of any
						visits between the alleged father and the child.
(p) Describe any physical resemblance
						between the alleged father and the child. Attach photographs, if
						available.
(q) Provide names and addresses of any
						witnesses to your relationship with the father. Consider friends and relatives
						who were aware of the parties' dating, ongoing relationship, or cohabitation
						during the period of conception.
If you are the father, provide details to
						"Yes" answers to statements j through n in Section III.
(j) Describe any food, clothing, gifts, or
						financial support you provided for the child.
(k) Describe where and when you lived with
						the child.
(l) Provide dates and circumstances of any
						visits between you and the child.
(m) Describe any physical resemblance
						between you and the child. Attach photographs, if available.
(n) Provide names and addresses of any
						witnesses to your relationship with the child's mother. Consider friends and
						relatives who were aware of the parties' dating, ongoing relationship, or
						cohabitation during the period of conception.
____________
Instructions for Affidavit in Support of
						Establishing Paternity--Page 3
**************************************************
The Paperwork Reduction Act of 1995
This information collection is conducted
						in accordance with
						45 CFR
						303.7 of the child support enforcement
						program. Standard forms are designed to provide uniformity and standardization
						for interstate case processing. Public reporting burden for this collection of
						information is estimated to average one hour per response. The responses to
						this collection are mandatory in accordance with
						45 CFR
						303.7. This information is subject to State
						and Federal confidentiality requirements; however, the information will be
						filed with the tribunal and/or agency in the responding State and may,
						depending on State law, be disclosed to other parties. An agency may not
						conduct or sponsor, and a person is not required to respond to, a collection of
						information unless it displays a currently valid OMB control number.
____________
Instructions for Affidavit in Support of
						Establishing Paternity--Page 4