Form HFS 3416E Rescission of Illinois Voluntary Acknowledgment of Paternity or Rescission of Denial of Parentage - Illinois

Form HFS3416E or the "Rescission Of Illinois Voluntary Acknowledgment Of Paternity Or Rescission Of Denial Of Parentage" is a form issued by the Illinois Department of Healthcare and Family Services.

Download a PDF version of the Form HFS3416E down below or find it on the Illinois Department of Healthcare and Family Services Forms website.

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Rescission of Illinois Voluntary Acknowledgment
of Paternity or Rescission of Denial of
File Date for ACU use only
Parentage
Purpose: THIS IS A LEGAL DOCUMENT. This form cancels the legal father and child relationship created by the previously signed Voluntary
Acknowledgment of Paternity and/or cancels the adjudication of the nonparentage of the presumed parent thereby making the presumed parent
responsible for all rights and duties of a parent. The form must be signed, witnessed and filed with the Department within 60 days from
the effective date of either the Voluntary Acknowledgment of Paternity (VAP), and/or the Denial of Parentage (Denial), or the date of a
proceeding relating to the child, whichever occurs earlier.
Instructions: PRINT in BLACK or BLUE ink. Do not cross out words or make corrections or your form will be rejected. If you make a mistake,
ask for a new form. See additional instructions on the reverse side of this form.
If using the Internet form, enter information and check for errors before printing. Forms with errors will be rejected.
Read carefully and complete all information before signing this form. Only one person must sign this form to withdraw the VAP and/or
the Denial. The other party who signed the VAP and/or the Denial will be notified of your withdrawal of consent. In addition, the Department
of Public Health’s Division of Vital Records will be notified to remove the father’s name from the child’s birth certificate and/or add the
presumed parent’s name to the child’s birth certificate. Call the Child Support Customer Service Call Center at 1-800-447-4278 if you have
questions.
G
G
I would like to withdraw the (check one):
Voluntary Acknowledgment of Paternity
Denial of Parentage
Name
Date of Birth (mm/dd/yy)
Address
City/State/Zip
Social Security Number
Full Name of Child (as shown or will be shown on Birth Certificate)
Child’s Date of Birth (mm/dd/yy)
Date VAP or Denial was Signed (mm/dd/yy)
Name of Other Person who Signed VAP or Denial (not the witness)
I understand that the legal father and child relationship established by signing the VAP is canceled or the adjudication of the non-
parentage of the presumed parent is canceled thereby making the presumed parent responsible for all rights and duties of a
parent. Paternity may be established by other means.
Signature
Date of Signature
Witness Information
Printed Name
Address
Signature
Phone Number
Date Signed
Mail to HFS/ACU, 110 W Lawrence Avenue, Springfield, IL 62704.
HFS 3416E (R-4-17)
For Official Use Only _____________________________________________________________________________________
Case #
Docket #
CP RIN
NCP RIN
Rescission of Illinois Voluntary Acknowledgment
of Paternity or Rescission of Denial of
File Date for ACU use only
Parentage
Purpose: THIS IS A LEGAL DOCUMENT. This form cancels the legal father and child relationship created by the previously signed Voluntary
Acknowledgment of Paternity and/or cancels the adjudication of the nonparentage of the presumed parent thereby making the presumed parent
responsible for all rights and duties of a parent. The form must be signed, witnessed and filed with the Department within 60 days from
the effective date of either the Voluntary Acknowledgment of Paternity (VAP), and/or the Denial of Parentage (Denial), or the date of a
proceeding relating to the child, whichever occurs earlier.
Instructions: PRINT in BLACK or BLUE ink. Do not cross out words or make corrections or your form will be rejected. If you make a mistake,
ask for a new form. See additional instructions on the reverse side of this form.
If using the Internet form, enter information and check for errors before printing. Forms with errors will be rejected.
Read carefully and complete all information before signing this form. Only one person must sign this form to withdraw the VAP and/or
the Denial. The other party who signed the VAP and/or the Denial will be notified of your withdrawal of consent. In addition, the Department
of Public Health’s Division of Vital Records will be notified to remove the father’s name from the child’s birth certificate and/or add the
presumed parent’s name to the child’s birth certificate. Call the Child Support Customer Service Call Center at 1-800-447-4278 if you have
questions.
G
G
I would like to withdraw the (check one):
Voluntary Acknowledgment of Paternity
Denial of Parentage
Name
Date of Birth (mm/dd/yy)
Address
City/State/Zip
Social Security Number
Full Name of Child (as shown or will be shown on Birth Certificate)
Child’s Date of Birth (mm/dd/yy)
Date VAP or Denial was Signed (mm/dd/yy)
Name of Other Person who Signed VAP or Denial (not the witness)
I understand that the legal father and child relationship established by signing the VAP is canceled or the adjudication of the non-
parentage of the presumed parent is canceled thereby making the presumed parent responsible for all rights and duties of a
parent. Paternity may be established by other means.
Signature
Date of Signature
Witness Information
Printed Name
Address
Signature
Phone Number
Date Signed
Mail to HFS/ACU, 110 W Lawrence Avenue, Springfield, IL 62704.
HFS 3416E (R-4-17)
For Official Use Only _____________________________________________________________________________________
Case #
Docket #
CP RIN
NCP RIN
Instructions for Rescission of Illinois Voluntary Acknowledgment of Paternity or Rescission of
Denial of Parentage
PURPOSE: The Rescission of Illinois Voluntary Acknowledgment of Paternity or Rescission of Denial of Parentage
(here after called the “Rescission”) is completed when either the biological mother, biological father, or presumed parent
wishes to withdraw the action of filing the HFS 3416B, Voluntary Acknowledgment of Paternity (here after called the
“VAP”) and/or the HFS 3416D, Illinois Denial of Parentage (here after called the “Denial”). The Rescission must be
signed, witnessed and filed with the Department within 60 days from the effective date of either the VAP and/or
the Denial, or the date of a proceeding relating to the child, whichever occurs earlier. Forms that contain errors
will be rejected. As a result, the VAP and/or Denial will not be withdrawn and the biological father’s name will
remain on the child’s birth certificate.
PLEASE READ AND COMPLETE ALL REQUESTED INFORMATION PRIOR TO SIGNING THIS FORM.
1.
Only one person must sign this form to withdraw the VAP and/or Denial.
2.
The other party(ies) who signed the VAP and/or Denial will be notified of your withdraw of consent. In addition,
the Department of Public Health’s Division of Vital Records will be notified to remove the father’s name from the
child’s birth certificate and/or add the presumed parent’s name to the child’s birth certificate.
3.
The person withdrawing the VAP and/or Denial must sign and date all forms in front of a witness. A witness must
be an adult age eighteen or older but cannot be the biological mother, biological father, presumed parent or the
child.
4.
Mail the Rescission to the Department’s:
Administrative Coordination Unit (ACU)
110 West Lawrence Avenue
Springfield, Illinois 62704
For more information about the Rescission or other related forms, 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. (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
Birth, Death, Other Records | IDPH
or 217-782-6554.
If you have any questions relating to completing this form, call the Child Support Customer Service Call Center at 1-800-
447-4278.
HFS 3416E (R-4-17)
IOCI17-0534
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