Affidavit of Father and Mother in Paternity Consent Form for Birth Registration

Amending the birth registration of a child of non-married parents requires the execution of this affidavit.

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Kansas Department of Health and Environment 
    Bureau of Epidemiology and Public Health Informatics  
      Office of Vital Statistics 
        1000 SW Jackson Street, Suite 120, Topeka, KS 66612-2221  
       (785) 296-1434 	
 
Paternity Consent Form for Birth Registration  
 
This completed consent form and a court order are required to amend a child’s birth registration under KSA  23-2204  when no 
father’s name appears on the child’s birth certificate and the mother was not married at the time of conception, birth,  or 
anytime in between.  Otherwise, an action under the Kansas Parentage Act is required to add the father’s name on the child’s 
birth certificate.  This completed form should be submitted by the court to the State Registrar along with the order required  by 
KSA 23- 2204. 	
 
 	
I have read this page.                                                                          _______________  	
   Father’s initials    Mother’s initials    Date 	 
VS211, revised  08/2016.              Page 1 of 3  
 	
Disclosures to BOTH Parents:	 	
Basic Rights and Responsibilities of Acknowledging Paternity  	
 
  	An acknowledgment of paternity creates a permanent father and child relationship which can only be ended by court 
order.  A person who wants to rev	oke the acknowledgment of paternity must file the request with the court before 	
the child is one year old, unless the person was under age 18 when the acknowledgment of paternity was signed.  A 
person under age 18 when the acknowledgment was signed has unt	il one year after his or her 18th birthday to file a 	
request, but if the child is more than one year old then, the judge will first consider the child’s best interests.  The 
person will have to show that the acknowledgment was based on fraud, duress (threa	t) or an important mistake of 	
fact, unless the request is filed within 60 days of signing the acknowledgment or before any court hearing about the 
child, whichever is earlier.  	
 
   Both the father and the mother are responsible for the care and support of t	he child.  If necessary, this duty may be 	
enforced through legal action such as a child support order, an order to pay birth or other medical expenses of the 
child, or an order to repay government assistance payments for the child’s care.  A parent’s willf	ul failure to support 	
his or her child is a crime.  	
 
  	Both the father and the mother have rights of custody and visitation with the child unless a court order changes their 
rights.  If necessary, custody and visitation rights may be spelled out in a court  order and enforced. 	
 
  	Both the father and the mother have the right to consent to medical treatment for the child unless a court order 
changes those rights.  	
 
   The child may inherit from the father and the father’s family or from the mother and the mot	her’s family.  The child 	
may receive public benefits, including, but not limited to, social security or private benefits, including, but not 
limited to, insurance or workers compensation because of the father -child or mother -child relationship.  	
 
   The fat	her or the mother may be entitled to claim the child as a dependent for tax or other purposes.  The father or 	
the mother may inherit from the child or the child’s descendants.  	
 
   Each parent has the right to sign or not sign an acknowledgment of paternity	.  Each parent has the right to talk with 	
an attorney before signing an acknowledgment of paternity.  Each parent has the right to be represented by an 
attorney in any future legal action involving paternity or their rights or duties as a parent.  Usually 	each person is 	
responsible for hiring his or her own attorney.

Please print or type.	  	
Father’s Affidavit  	
I, ________________________________________________________________, hereby swear or affirm that:      First, middle, and last name of father  
 
   I have read the disclosure of basic rights and responsib ilities of acknowledging paternity printed on the back of this form, and I have 
had and opportunity to obtain legal advice if I so desire.  
 
   I am the father of __________________________________________________________, born on __ __ / __ __ / __ __ __ __ , in 
    First, middle, and last name of child as shown on birth certificate.  Date of birth (mm/dd/yyyy)  
 
  ______________________________________ to _______________________________________________________.     City & State of birth   Full name of mother as shown on the birth certificate. 
 
   I desire to amend the birth certificate of this child pursuant to KSA 23- 2223. 
 
Additional information required:   Father’s state of birth: _______________________________ 
 
  Father’s date of birth:	
(mm/dd/yyyy)	 __ __ / __ __ / __ __ __ __  Father’s highest education: ___________________________ 
 
  Father’s Social Security Number: __ __ __ / __ __ / __ __ __ __  Father’s race: ______________________________________ 
 
  Father’s address: _____________________________________________________________________________________________  	
     Street   City    State   Zip code  
 
                     _____________________________________            Signature of Father  
 
Subscribed and sworn to before me at ___________________________ on this __________ day of ______________________, _______.  
 
           _____________________________________  
          Signature of Judge or authorized Hearing Officer  
- -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -  -   	
Mother’s Affidavit  	
I, ________________________________________________________________, hereby swear or affirm that:      First, middle, and last name of mother   
  I have read the disclosu re of basic rights and responsibilities of acknowledging paternity printed on the back of this form, and I have 
had and opportunity to obtain legal advice if I so desire.  
 
   I am the mother of __________________________________________________________, bor n on __ __ / __ __ / __ __ __ __, in 
   First, middle, and last name of child as shown on birth certificate.    Date of birth (mm/dd/yyyy)  
 
  ______________________________________.     City & State of birth  
 
   ____________________________________________ is th e father of this child, and I desire to amend the birth certificate of this child  
                             	Full name of Father  
 	
pursuant to KSA 23- 2223.  Mother’s daytime phone number: (__ __ __) __ __ __ -  __ __ __ __  
 
Mother’s date of birth:	
(mm/dd/yyyy) 	__ __ / __ __ / __ __ __ __  Mother’s Social Security Number __ __ __ / __ __ / __ __ __ __  
 
Mother’s address: ________________________________________________________________________________________________  	
    Street   City      State   Zip code  
 
       	
    _____________________________________  	          Signature of Mother  
 
Subscribed and sworn to before me at ___________________________ on this __________ day of ______________________, _______.  
 
             _____________________________________  
          Signature of Judge or authorized Hearing Officer  
               
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Kansas Department of Health and Environment

Bureau of Epidemiology and Public Health Informatics 
Office of Vital Statistics  
1000 SW Jackson Street, Suite 120, Topeka, KS 66612-2221  
(785) 296-1434  
 	
 
The District Court of __________________________________________________  County, Kansas  
 	
In the Matter of the Certificate of Live Birth # ________________________________________ ,  
 
of: ______________________________________________ (name of child as shown on birth certificate)  
 	
Order to Prepare New Birth Registration  
 	
NOW  on this ____________________________________ day of ___________________________________ , ____________, the above 
captioned matter is considered.  
 
__________________________________ (mother’s name) and ________________________________________ (father’s name) request 
the birth certificate of the child named in the above caption be amended pursuant to KSA  23-2223.  
 
 
 
Upon hearing the evidence presented and being fully advised in the premises, the following findings are made:  
  1.  The court has jurisdiction pursuant to KSA 23- 2223. 
2.  The child named in the above caption is a minor.  
3.  The mother and father, as above named, are the parents of the child and they desire to amend the  birth registration of the child. 
4.  A certified copy of the birth certificate of the child has been exhibited in court.  
5.  The birth certificate of the child:  
a.   Fails to name the (father/mother*) of the child and the (father’s/mother’s*) name should appear thereo n as it appears above. 
b.   Contains an error in the name of the (father / mother / child*).  The name on the original birth certificate reads  
_______________________________________________________________________________ but should read 
______________________ ______/____________________________/_______________________________.**  
  First     Middle     Last 
c.   Shows the last name of the child as _____________________________________________ and should be changed to that 
of the (father/mother*) ________________________ ____________________ (father’s/mother’s*) last name.  
 
IT IS THEREFORE ORDERED that the State Registrar amend the birth certificate of the child named in the above caption to reflect the 
change stated in finding number 5, above.  
 
IT IS FURTHER ORDERED that  the State Registrar seal this order, the affidavits accompanying this order, and the original birth 
certificate of the child and allow inspection of them only as provided in KSA 23- 2222 and amendments thereto.  
 
 
 
Affix Court Seal                       Certif ied by: 
 
              ________________________________ 
               	
Judge or Authorized Hearing Officer  
*Circle the appropriate item in parenthesis.  
 
**This court order is not to be used in lieu of adoption or stepparent adoption procedures.  
                  	
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