Affidavit Of Unwed Mother

Print Form STATE OF MISSOURI COUNTY OF ST. CHARLES ) ) ss. ) IN THE CIRCUIT OF ST. CHARLES COUNTY, MISSOURI PROBATE DIVISION IN THE MATTER OF ______________________________________________ Minor #_________________________ AFFIDAVIT OF UNWED MOTHER I, ___________________________________, the mother of ___________________, a minor ____________________child born on the ______ day of ___________________, _______, in the County of ____________________, State of Missouri, do state that said child was conceived and born out of wedlock, and that I am the only person having legal custody and the right to legal custody and the right to legal custody of said child. No man has filed an affidavit affirmatively asserting his paternity to said child; the child's birth certificate does not name a father; and, I do not now desire to name the putative father of said child. Further, the putative father has not paid or assumed any responsibility for my medical and hospital expenses relating to the pregnancy of this child nor have I, said child and the putative father lived together as a family unit. Further, the putative father has not received this child in his own home, he has not held h____ out to be his own; and, he has not supported the child in a continuous ad regular fashion. I, ________________________, the mother of _______________________, affirm that the foregoing affidavit is true to the best of my knowledge and belief. ________________________________ Mother Signature ________________________________ Guardian Ad Litem of Minor STATE OF MISSOURI, County of St. Charles, On this ______ day of ________________, _______ before me _______________________, a notary public/clerk in and for said state, personally appeared _______________________, know to me to be the person__ who executed the within document and acknowledged to me that __h____ executed the same for the purposes therein stated. Subscribed and sworn to before me this ____ day of _______________, _______. _________________________________ Clerk Notary Public BY:______________________________ Deputy Clerk American LegalNet, Inc. www.FormsWorkFlow.com (seal) Notary commission expires: