Form HFS 3416B Illinois Voluntary Acknowledgment of Paternity - Illinois

Form HFS3416B or the "Illinois Voluntary Acknowledgment Of Paternity" is a form issued by the Illinois Department of Healthcare and Family Services.

Download a PDF version of the Form HFS3416B down below or find it on the Illinois Department of Healthcare and Family Services Forms website.

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Illinois Voluntary Acknowledgment of Paternity
File Date for ACU use only
PLEASE READ ALL PARTS OF THIS FORM INCLUDING YOUR RIGHTS AND
RESPONSIBILITIES AND INSTRUCTIONS ON THE OTHER SIDE BEFORE
COMPLETING THE FOLLOWING INFORMATION.
ALL ITEMS MUST BE ANSWERED
Child’s Information as shown or will be shown on Birth Certificate
Print all requested information
Child’s Name (First)
Middle (if any)
Last (same as on birth certificate)
Suffix (Jr, II, III)
Date of Birth (mm/dd/yy)
Gender
Name of Hospital or Address of Place of Birth
City, County, and State of Birth
M
F
Biological Father’s Name (first)
Middle (if any)
Last
Suffix (Jr, II, III)
Place of Birth (city, state or foreign country address)
Date of Birth (mm/dd/yy)
SSN/TIN
Address (street address and/or PO box)
City, State, and Zip
Daytime Phone (
)
include area code
st
Biological Mother’s Name (First)
Middle (if any)
Current Last Name
Maiden Name (before 1
marriage)
Place of Birth (city, state or foreign country address)
Date of Birth (mm/dd/yy)
SSN/TIN
Address (street address and/or PO box)
City, State, and Zip
Daytime Phone (
)
include area code
Were you married to or in a civil union with a person other than the above named father when this child was born or within 300 days before this child was
born?
Yes
No
If yes, that person is presumed to be the father (presumed parent) of this child and you are required to provide the presumed parent’s name (first/middle/last)
. A Denial of Parentage must also be completed by the biological mother and presumed
parent to place the biological father’s name on this child’s birth certificate.
By signing I acknowledge that I have read the rights and responsibilities and instructions on the other side of this form. I have been
provided an oral explanation about the VAP and understand my rights and responsibilities created and waived by signing this form.
I UNDERSTAND THAT I CAN REQUEST A GENETIC TEST REGARDING THE CHILD’S PATERNITY. BY
SIGNING THIS FORM I GIVE UP MY RIGHT TO A GENETIC TEST.
Each parent must sign and date this form in the presence of a witness age 18 or older. The witness must not be a parent or child named on the VAP.
BIOLOGICAL FATHER: Under the penalties of perjury provided by Section
BIOLOGICAL MOTHER: Under the penalties of perjury provided by Section
1-109 of the Illinois Code of Civil Procedure, I certify that my statements in
1-109 of the Illinois Code of Civil Procedure, I certify that my statements in
this document are true and correct. I acknowledge that I am the biological
this document are true and correct. I am the birth mother of the above named
father of the above named child and I give my permission to enter my name
child and I give my permission to enter the biological father’s name as the
as the legal father on the birth certificate. I understand that the
legal father on the birth certificate. I understand that the acknowledgment is
acknowledgment is the same as a court order for parentage of the child and
the same as a court order for parentage of the child and that a challenge to
that a challenge to the acknowledgment is allowed only under limited
the acknowledgment is allowed only under limited circumstances and is
circumstances and is generally not allowed after 2 years.
generally not allowed after 2 years.
Biological Father’s Signature
Biological Mother’s Signature
Witness Information
Witness Information
Printed Name
Printed Name
Signature
Signature
Address
Address
Phone Number
Phone Number
Date Parties Signed
Date Parties Signed
HFS 3416B (R-4-17) To request a certified copy of the VAP go to
www.childsupport.illinois.gov
and complete and follow instructions on
HFS
3416H, Request
for a Certified copy of the Voluntary Acknowledgment of Paternity and/or Denial of Parentage.
For Official Use Only
Case #
Docket #
CP RIN
NCP RIN
Illinois Voluntary Acknowledgment of Paternity
File Date for ACU use only
PLEASE READ ALL PARTS OF THIS FORM INCLUDING YOUR RIGHTS AND
RESPONSIBILITIES AND INSTRUCTIONS ON THE OTHER SIDE BEFORE
COMPLETING THE FOLLOWING INFORMATION.
ALL ITEMS MUST BE ANSWERED
Child’s Information as shown or will be shown on Birth Certificate
Print all requested information
Child’s Name (First)
Middle (if any)
Last (same as on birth certificate)
Suffix (Jr, II, III)
Date of Birth (mm/dd/yy)
Gender
Name of Hospital or Address of Place of Birth
City, County, and State of Birth
M
F
Biological Father’s Name (first)
Middle (if any)
Last
Suffix (Jr, II, III)
Place of Birth (city, state or foreign country address)
Date of Birth (mm/dd/yy)
SSN/TIN
Address (street address and/or PO box)
City, State, and Zip
Daytime Phone (
)
include area code
st
Biological Mother’s Name (First)
Middle (if any)
Current Last Name
Maiden Name (before 1
marriage)
Place of Birth (city, state or foreign country address)
Date of Birth (mm/dd/yy)
SSN/TIN
Address (street address and/or PO box)
City, State, and Zip
Daytime Phone (
)
include area code
Were you married to or in a civil union with a person other than the above named father when this child was born or within 300 days before this child was
born?
Yes
No
If yes, that person is presumed to be the father (presumed parent) of this child and you are required to provide the presumed parent’s name (first/middle/last)
. A Denial of Parentage must also be completed by the biological mother and presumed
parent to place the biological father’s name on this child’s birth certificate.
By signing I acknowledge that I have read the rights and responsibilities and instructions on the other side of this form. I have been
provided an oral explanation about the VAP and understand my rights and responsibilities created and waived by signing this form.
I UNDERSTAND THAT I CAN REQUEST A GENETIC TEST REGARDING THE CHILD’S PATERNITY. BY
SIGNING THIS FORM I GIVE UP MY RIGHT TO A GENETIC TEST.
Each parent must sign and date this form in the presence of a witness age 18 or older. The witness must not be a parent or child named on the VAP.
BIOLOGICAL FATHER: Under the penalties of perjury provided by Section
BIOLOGICAL MOTHER: Under the penalties of perjury provided by Section
1-109 of the Illinois Code of Civil Procedure, I certify that my statements in
1-109 of the Illinois Code of Civil Procedure, I certify that my statements in
this document are true and correct. I acknowledge that I am the biological
this document are true and correct. I am the birth mother of the above named
father of the above named child and I give my permission to enter my name
child and I give my permission to enter the biological father’s name as the
as the legal father on the birth certificate. I understand that the
legal father on the birth certificate. I understand that the acknowledgment is
acknowledgment is the same as a court order for parentage of the child and
the same as a court order for parentage of the child and that a challenge to
that a challenge to the acknowledgment is allowed only under limited
the acknowledgment is allowed only under limited circumstances and is
circumstances and is generally not allowed after 2 years.
generally not allowed after 2 years.
Biological Father’s Signature
Biological Mother’s Signature
Witness Information
Witness Information
Printed Name
Printed Name
Signature
Signature
Address
Address
Phone Number
Phone Number
Date Parties Signed
Date Parties Signed
HFS 3416B (R-4-17) To request a certified copy of the VAP go to
www.childsupport.illinois.gov
and complete and follow instructions on
HFS
3416H, Request
for a Certified copy of the Voluntary Acknowledgment of Paternity and/or Denial of Parentage.
For Official Use Only
Case #
Docket #
CP RIN
NCP RIN
Instructions for Completing the
Illinois Voluntary Acknowledgment of Paternity
PURPOSE: The Voluntary Acknowledgment of Paternity (hereafter called VAP) legally establishes the biological father and child relationship
(when the biological father is not married to the child’s biological mother) and allows the biological father’s name to be placed on the
birth certificate. The biological father becomes the legal father of the child when the VAP is properly signed, witnessed and filed with the
Illinois Department of Healthcare and Family Services (hereafter called HFS), creating certain legal rights and responsibilities for the child and
the parents. The VAP may be completed before your child is born, but is not valid until the child is born and the VAP is filed with HFS. A VAP
(and Denial, if necessary) may be completed after you leave the hospital, and the VAP (and Denial, if necessary) may also be completed for
a child born in another state. Forms that contain errors will be rejected. As a result, paternity is not established and the biological
father’s name will not be placed on the birth certificate.
If the biological mother is or was married to or in a civil union with a person who is not the biological father when the child was born or within
300 days before this child was born, a Denial of Parentage (hereafter called Denial) must be signed, witnessed and filed in conjunction with
the completion of the VAP by the biological mother and biological father.
YOUR RIGHTS AND RESPONSIBILITIES
I understand that:
1.
the VAP is a legal document, and when signed, witnessed and filed with HFS, is the same as a court order determining the legal
relationship between a biological father and child.
2.
if I am a minor, I have the right to sign and have this form witnessed without my guardian’s permission.
3.
it is my responsibility to provide financial support for the child that may include child support and medical support starting from the child’s
birth until the child is at least 18 years old.
4.
this VAP does not give parental responsibility allocation or parenting time to the biological father; however, it gives him the right to ask for
parental responsibility allocation and parenting time.
5.
either the biological mother or biological father may rescind the action by signing a Rescission of VAP. The Rescission must be signed,
witnessed and filed with HFS within 60 days from the effective date of the VAP or the date of a proceeding relating to the child,
whichever occurs earlier.
INSTRUCTIONS – USE BLACK OR BLUE INK
1.
The biological mother must indicate “yes” or “no” if she is or was married to or in a civil union with a person other than the biological
father when this child was born or within 300 days before this child was born. If “yes”, the biological mother must provide the name of
that person (referred to as the presumed parent). The presumed parent and biological mother must sign the Denial and the biological
mother and biological father must sign the VAP to establish legal paternity and place the biological father’s name on the birth certificate.
If the presumed parent and the biological mother do not sign the Denial, the presumed parent is considered to be the parent of
the child and that person’s name, by law, must be placed on the birth certificate.
2.
Each person must sign and date all forms in front of a witness. A witness must be an adult age 18 or older but cannot be the parents or
child named on the VAP.
3
If the VAP (and Denial, if necessary) is completed at the hospital when the child is born, hospital staff will add the biological father’s
name to the birth certificate and send the VAP to HFS for filing.
4.
If the VAP (and Denial, if necessary) is not completed at the hospital, each person must sign and date the form(s) in front of a witness,
age 18 or older but not the parents or child named on the VAP, and submit the original documents to HFS.
5.
Send only the original document. Do not send a photocopy (must be original signatures)
Mail original document to:
Administrative Coordination Unit (ACU)
(copies will be rejected)
110 West Lawrence Avenue
Springfield, Illinois 62704
The Administrative Coordination Unit (ACU) will file the original VAP and send a copy of the completed VAP (and Denial, if necessary) to
either the: 1. Illinois Department of Public Health, Division of Vital Records (for Illinois births); or 2. Vital Records Office in affected state (for
out of state births)
For more information about the VAP, ask hospital staff for the HFS 3416A, “Two Parents…Give Your Child Hope” flyer. You may also obtain
a copy from state and local registrars, county clerks, Department of Human Services offices, Child Support Services offices or by going to the
Forms and Brochures
section of the Child Support Services website.
This form is available in English and Spanish upon request and on the HFS website (www.childsupport.illinois.gov). The Spanish version
may be used for translation purposes only. The Spanish version is not acceptable as a legal document. Only the English version of this
document may be signed, witnessed and filed with HFS.
SI LAS PIDE, TENEMOS VERSIONES EN ESPAÑOL DISPONIBLES Y EN EL SITIO DEL DEPARTAMENTO EN EL INTERNET EN
(WWW.CHILDSUPPORT.ILLINOIS.GOV), PERO SÓLO SE PUEDEN USAR PARA PROPÓSITOS DE TRADUCCIÓN. LAS VERSIONES
EN ESPAÑOL NO SON DOCUMENTOS LEGALES ACEPTABLES. SÓLO LA VERSIÓN EN INGLES DEL DOCUMENTO SE PUEDE
FIRMAR Y ATESTIGUAR.
If you have any questions relating to the child’s birth certificate, contact the Department of Public Health’s Division of Vital Records
at www.idph.state.il.us/vitalrecords or 217-782-6554.
Get oral explanation and answers to questions relating to the completion of this form by calling the Child Support Customer Service Call
Center at 1-800-447-4278.
HFS 3416B (R-4-17)
IOCI17-0532
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