Form HFS 3416D Illinois Denial of Parentage - Illinois

Form HFS3416D is a Illinois Department of Healthcare and Family Services form also known as the "Illinois Denial Of Parentage". The latest edition of the form was released in April 1, 2017 and is available for digital filing.

Download an up-to-date Form HFS3416D in PDF-format down below or look it up on the Illinois Department of Healthcare and Family Services Forms website.

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File Date for ACU use only
Illinois Denial of Parentage
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.
THIS FORM IS TO BE USED ONLY BY PARTIES WHO ARE OR WERE MARRIED OR IN A CIVIL UNION WHEN
THE CHILD WAS BORN; OR THE MARRIAGE OR CIVIL UNION WAS LEGALLY TERMINATED WITHIN 300
DAYS OF THE DATE THE CHILD WAS BORN.
Child’s Information as shown on or will be shown on Birth Certificate
Print all requested information
Child’s Name (First)
Middle (if any)
Last (same as on or will be on birth certificate)
Suffix (Jr, II, III)
Date of Birth (mm/dd/yy)
Gender
Name of Hospital or Place of Birth
City, County, and State of Birth
M
F
Presumed Parent - Person married to or in a civil union with the biological mother when the child is born or if the child is born within 300 days after the marriage
or civil union has ended.
Presumed Parent’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
Date of Marriage or Civil Union
By signing I acknowledge that I have read the rights and responsibilities and instructions on the other side of this form 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 person must sign and date this form in the presence of a witness age 18 or older. The witness must not be a person named on this form.
PRESUMED PARENT: Under the penalties of perjury provided by Section
BIOLOGICAL MOTHER: Under the penalties of perjury provided by
1-109 of the Illinois Code of Civil Procedure, I certify that my statements in
Section 1-109 of the Illinois Code of Civil Procedure, I certify that my
this document are true and correct
statements in this document are true and correct.
Presumed Parent’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 3416D (R-4-17) To request a certified copy of the Denial 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
File Date for ACU use only
Illinois Denial of Parentage
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.
THIS FORM IS TO BE USED ONLY BY PARTIES WHO ARE OR WERE MARRIED OR IN A CIVIL UNION WHEN
THE CHILD WAS BORN; OR THE MARRIAGE OR CIVIL UNION WAS LEGALLY TERMINATED WITHIN 300
DAYS OF THE DATE THE CHILD WAS BORN.
Child’s Information as shown on or will be shown on Birth Certificate
Print all requested information
Child’s Name (First)
Middle (if any)
Last (same as on or will be on birth certificate)
Suffix (Jr, II, III)
Date of Birth (mm/dd/yy)
Gender
Name of Hospital or Place of Birth
City, County, and State of Birth
M
F
Presumed Parent - Person married to or in a civil union with the biological mother when the child is born or if the child is born within 300 days after the marriage
or civil union has ended.
Presumed Parent’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
Date of Marriage or Civil Union
By signing I acknowledge that I have read the rights and responsibilities and instructions on the other side of this form 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 person must sign and date this form in the presence of a witness age 18 or older. The witness must not be a person named on this form.
PRESUMED PARENT: Under the penalties of perjury provided by Section
BIOLOGICAL MOTHER: Under the penalties of perjury provided by
1-109 of the Illinois Code of Civil Procedure, I certify that my statements in
Section 1-109 of the Illinois Code of Civil Procedure, I certify that my
this document are true and correct
statements in this document are true and correct.
Presumed Parent’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 3416D (R-4-17) To request a certified copy of the Denial 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 Denial of Parentage
PURPOSE: The Denial of Parentage (hereafter called Denial) is signed, witnessed and filed with the Department of Healthcare and Family
Services (hereafter called HFS) when the biological mother of the child is or was married or in a civil union when this child was born or within
300 days before this child was born, the presumed parent is not the biological father and the biological father acknowledges paternity of the
child by signing and filing the Voluntary Acknowledgment of Paternity (hereafter called VAP), with HFS. 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.
YOUR RIGHTS AND RESPONSIBILITIES
I understand that:
1.
this is a legal document and is valid when signed, witnessed and filed with HFS in conjunction with a valid VAP that is signed, witnessed
and filed with HFS. I understand a valid Denial by a presumed parent filed with HFS in conjunction with a valid VAP is equivalent to an
adjudication of the non-parentage of the presumed parent and discharges the presumed parent from all rights and duties of a parent.
2.
the biological mother and the presumed parent must sign and file the Denial with HFS and that the biological mother and biological father
must sign and file the VAP with HFS to establish legal paternity and place the biological father’s name on the child’s birth certificate.
3.
if the biological mother and the presumed parent do not sign and file the Denial with HFS and the biological mother and biological father
do not sign and file the VAP with HFS, the presumed parent, by law, is considered to be the parent and that person’s name must be
placed on the child’s birth certificate.
4.
when the biological mother and the presumed parent sign and file the Denial with HFS and the biological mother and biological father sign
and file the VAP with HFS, the biological father becomes the legal father of the child for all purposes. The presumed parent is essentially
adjudicated to a status of non-parentage and is discharged from all rights and duties of a parent.
5.
either the biological mother or presumed parent of the child may withdraw the action of signing and filing the Denial with HFS by signing
and filing a Rescission of Voluntary Acknowledgment of Paternity or Rescission of Denial of Parentage (hereafter called Rescission). The
Rescission must be signed, witnessed and filed with the Department within 60 days from the effective date of the Denial or the date of a
proceeding relating to the child, whichever occurs earlier. Upon Department verification of the Rescission, the presumed parent is legally
responsible for support of the child.
6.
either the biological mother or biological father of the child may withdraw the action of signing and filing the VAP with HFS by signing and
filing a Rescission. The Rescission must be signed, witnessed and filed with the Department within 60 days from the effective date of the
VAP or the date of a proceeding relating to the child, whichever occurs earlier.
Upon Department verification of the Rescission, the
presumed parent is legally responsible for support of the child.
INSTRUCTIONS – USE BLACK OR BLUE INK
1.
Each person must sign and date all forms in front of a witness. A witness must be an adult age eighteen or older but cannot be a person
named on the form he or she is asked to witness.
2.
If you are completing the Denial and VAP at the hospital when the child is born, hospital staff will add the biological father’s name to the
birth certificate and send the documents to HFS for filing.
3.
You may complete the Denial and VAP before your child is born, but neither is valid until the child is born and the documents are filed
with HFS.
4.
You may complete the Denial and VAP for a child born in another state.
5.
When the Denial and VAP are not completed at the hospital, the parents must sign and date the form(s) in front of an adult witness and
file the completed documents with HFS.
Mail original document to:
(copies will be rejected)
Administrative Coordination Unit (ACU)
110 West Lawrence Avenue
Springfield, Illinois 62704
The Administrative Coordination Unit (ACU) will file the Denial and send a copy of the completed Denial and VAP 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 (
). The Spanish version may
to
www.childsupport.illinois.gov
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 the Department.
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. (translation from English paragraph above)
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 3416D (R-4-17)
IOCI17-0533

Download Form HFS 3416D Illinois Denial of Parentage - Illinois

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