Affidavit Of Birth Mother {NHJB-2189-FP}

THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) AFFIDAVIT OF BIRTH MOTHER (RSA 170-B) I, , of under oath, do state the following: (Please check all appropriate boxes.) 1. I am the mother of in (city, state) 2. The name of the child's father is his mailing address is 3. I do not wish to identify the name of the child's father. 4. Birth mother's current marital status: If applicable, date of marriage Single Married Divorced Widowed ; , born on , , If married, divorced or widowed, name of spouse date of divorce 5. I am not, and have not, lived with any man who is providing or has provided support to me or my child, and who is holding himself out to be the child's father. 6. I am living with, or have lived with, , who is providing or has provided support to me or my child, and who is holding himself out to be the child's father. His mailing address is: 7. To the best of my knowledge, no person holds himself out to be the father of my child named above, or has filed a claim with the Child Support Services, Division of Health and Human Services. 8. In order for the Division of Health and Human Services to complete a search of its putative father's registry, I verify that the only names I have ever used since my birth are as follows: (Please print the full name used.) Date Birth Mother's signature State of This instrument was acknowledged before me on My Commission Expires Affix Seal, if any NHJB-2189-FP (10/01/2006) , County of by Signature of Notarial Officer / Title American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 1