AFFIDAVIT OF PARENTAGE

Michigan Department of Health and Human Services State File Number

Division for Vital Records and Health Statistics
AOP Number
We affirm under penalty of perjury that we are the natural parents of:

First Middle Last Suffix

who was born in on

Hospital Name, City, County, State Date of Birth
and that we sign this affidavit to establish the paternity for this child. We hereby consent that the name of the natural father may be included on the certificate
of birth for the child. We wish the child’s name to be recorded as:

First Middle Last Suffix

In signing this form, we understand that:

(a) This is a legal document. (g) By signing this affidavit, we waive the following:
(b) Completion of the affidavit is voluntary. (i) The right to blood or genetic tests to determine if the man is the
(c) The mother has initial custody of the child, without prejudice to the biological father of the child.
determination of either parent’s custodial rights, until otherwise determined (ii) Any right to a court-appointed attorney, including the Prosecuting
by the court or agreed upon by the parties in writing and acknowledged by Attorney, to represent either party in a court action to determine if the
the court. This grant of initial custody to the mother shall not, by itself, affect man is the biological father of the child.
the rights of either parent in a proceeding to seek a court order for custody (iii) The right to a trial to determine if the man is the biological father of
or parenting time. the child.
(d) Either parent may assert a claim in court for parenting time or custody. (h) In order to revoke the Affidavit of Parentage, an individual must file a
(e) Both parents have a right to notice and a hearing regarding the adoption of claim as provided under the Revocation of Paternity Act (Michigan
the child. Compiled Law [MCL] 722.1437).
(f) Both parents have the responsibility to support the child and to comply with
a court or administrative order for the child’s support.
Further, the mother states that she was not married when this child was born or conceived; or that this child, though born or conceived during a marriage, is
not an issue of that marriage as determined by a court of law.

FATHER’S INFORMATION MOTHER’S INFORMATION

First Name First Name

Middle Name Middle Name

Last Name Last Name

Date of Birth: Place of Birth: (State or Social Security Number Date of Birth: Place of Birth: (State or Social Security Number
(MM/DD/YYYY) Country) (MM/DD/YYYY) Country)

Current Address (Street, Apt. No., City, State, Zip) Current Address (Street, Apt. No., City, State, Zip)

To the best of my knowledge, the above information is true: To the best of my knowledge, the above information is true:

Father’s Signature Date Mother’s Signature Date

NOTARY SECTION
Notary Public in and for County, Michigan Notary Public in and for County, Michigan

Acting in the county of Acting in the county of

Signature Printed Name Signature Printed Name

Signature and sworn to before me this day of 20 Signature and sworn to before me this day of 20

Commission expiration date Commission expiration date

QUALIFIED WITNESS SECTION – Facility Use Only (if not notarized, complete as defined on reverse of form)
Signature of Father’s Witness Printed Name of Witness Signature of Mother’s Witness Printed Name of Witness

Witness Place of Employment Witness Place of Employment

Witness Work Address (Street, City, State, Zip) Witness Work Address (Street, City, State, Zip)

DCH-0682 (Rev. 4-16) By authority of Act 305 of 1996 as amended. 1

 AFFIDAVIT OF PARENTAGE INSTRUCTIONS

This form can be used to establish the parentage of a child and may be used to have information on the father of a child added to the
certificate of birth for the child. This affidavit may be completed at the time of the child’s birth or at any other time after the birth. Completion
of this affidavit is voluntary. It indicates the parents wish to acknowledge parentage of a child.

It is intended for use by couples who were not married at the time the child was conceived nor at the time of birth. In instances where the
mother was married to someone other than the father when the child was conceived or delivered, a court ruling of her husband’s non-
paternity is necessary in order to first establish that the child is not the husband’s child.

Proper completion of the form is very important. Forms that are not properly completed will not be accepted for filing. The form must be
legible and must be typed or printed in ink. The affidavit must be signed by the mother and father in the presence of a Notary Public or a
qualified witness. A qualified witness is an employee of one of the following: a hospital, publicly funded or licensed health clinic,
pediatric office, Friend of the Court, Prosecuting Attorney, court, Michigan Department of Health and Human Services, county
health agency, county records department, Head Start program, local social services provider, county jail, or state prison. The form
may be signed and witnessed or notarized by both parents at different times. At a minimum, the following items must be provided: the full
names of the child, the mother and the father; the date and place of the child’s birth; the address of each parent; and the birth place of each
parent.

The same qualified witness and/or notary may serve as both the mother’s qualified witness/notary and the father’s qualified witness/notary,
but (s)he must fill out the information in both the mother’s and father’s sections of the form. A qualified witness/notary must verify the identity
of the mother and father before the qualified witness/notary signs the form by checking the mother’s and father’s identification. Examples of
identification include a driver’s license, passport, state-issued identification, etc.

There is no fee for filing the affidavit with the Central Paternity Registry. Once filed, copies of the affidavit can be obtained by either parent,
by the child, or by a guardian or legal representative of a parent or the child. Certified copies of the affidavit are available from the Central
Paternity Registry for $34.00 (additional copies are $16.00 each) and can be requested at the time of filing.

Adding a Father to the Birth Certificate –

Establishing Paternity at the Hospital – If this affidavit is completed at the time of birth and provided to hospital staff before the birth certificate
is prepared and filed, the birth certificate will be completed to include the father with no need for a separate application or fee. When
completed at the time of birth and used as the basis for recording the father on the original certificate of birth, hospital staff must forward the
original affidavit, along with the original birth certificate, to the local registrar. The local registrar will forward the affidavit to the Central
Paternity Registry for final filing.

Establishing Paternity After Leaving the Hospital – Birth certificates are not automatically changed when an affidavit is filed. Changes to
registered birth records can be requested based upon a properly completed affidavit and an Application to Add a Father on a Michigan Birth
Record (form DCH-0848). If the affidavit is going to be used to add the father’s name to a Michigan birth record, the affidavit must not be
mailed to the Central Paternity Registry. It must be mailed along with the correct application to the address listed on the application. A
birth record can be changed to reflect the father listed on the affidavit if no other man is recorded on the record as the child’s father. Should a
conflict exist, a court determination of paternity may become necessary.

There is a fee for each birth record change, as is noted in the payment section of the correction application. An application to correct a birth
certificate is available from the Office of the County Clerk, the State Vital Records office recorded message 517-335-8656, or can be
downloaded from the Michigan Department of Health and Human Services website at:
www.michigan.gov/documents/add_dad_6589_7.pdf.

To file the affidavit and request a copy and/or to change the birth record, mail the completed affidavit, the required fee and, for a birth record
change, a completed Application to Add a Father on a Michigan Birth Record (form DCH-0848) to:

Vital Records Changes

PO Box 30721
Lansing, MI 48909

To simply file the affidavit to establish paternity and not request a copy or a change to the birth record, mail to:

Central Paternity Registry

Division for Vital Records and Health Statistics
Michigan Department of Health and Human Services
PO Box 30691
Lansing, MI 48909

(Completion of this form is voluntary)

Alteration of this form or the making of false statements with the affidavit for the purposes of deception is a crime. [MCL 333.2894]

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race,
religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression,
political beliefs or disability.
DCH-0682 (Rev. 4-16) By authority of Act 305 of 1996 as amended. 2