MONTANA Department of Public Health and Human Services

Public Health and Safety Division ♦ Financial Services & Operations Bureau
Office of Vital Records ♦ 111 N Sanders Rm 6 ♦ PO Box 4210 ♦ Helena, MT 59604-4210
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Phone: (406) 444-2685 ♦ Fax: (406) 444-1803
Greg Gianforte, Governor
Charles T. Brereton, Director

Dear New Parent:

Congratulations on the birth of your new child.

A certificate of birth for every child born in Montana must be completed and filed
within ten calendar days after the date of birth. 37.8.301 (1) Administrative Rules of
Montana (ARM)
In order to place a birth certificate on file with the State of Montana, we require that the
enclosed Homebirth worksheet be completed, and that three documents be provided to
prove the following:
1. Proof of Pregnancy
2. Proof of residence in Montana at the time of birth or proof that the birth occurred
in Montana.
3. Proof of Live birth
Within this packet you should have the following forms:
Form A: Requirements for filing an Unattended Homebirth (4 pages)
Form B: Homebirth Worksheet (2 pages)
Form C: Paternity Acknowledgment
Form D: Notice of Withdrawal of Paternity Acknowledgment
Form E: Affidavit of Non-Paternity
Also included are instructions for filling out the certifier and attendant information, as
well as the marital and paternity questions.
We have compiled this handout to assist you in obtaining the required documents to file
your child’s birth certificate.
Please do not contact your local Registrar! If at any time you have any questions, please
contact the State of Montana Office of Vital Records at (406) 444-2685
These forms can also be printed from the following web site:
https://dphhs.mt.gov/vitalrecords/vitalrecordsforms
Please mail the completed original Home birth worksheet and original documents to:
Montana Vital Records
PO Box 4210
Helena, MT 59604
To contact DPHHS Director: PO Box 4210 ♦ Helena, MT 59604-4210 ♦ (406) 444-5622 ♦ https://dphhs.mt.gov
 REQUIREMENTS FOR FILING AN UNATTENDED HOMEBIRTH

If a child is born at home, mother and/or father are responsible for filing the birth certificate, as stated in
50-15-221 (4), MCA. Please include evidence of the pregnancy, evidence that the infant was born alive,
and evidence the birth occurred within this state. If the homebirth worksheet is received in our office after
the child’s first birthday, a delayed birth certificate must be filed.

Please complete and sign the enclosed homebirth worksheet.

Documentation to substantiate the facts of this birth is required to file a home birth. Documents used as
proof of the fact of birth must be dated within 30 days of the date of birth and must establish the following:

1. One document must show: Proof of pregnancy

2. One document must show: Proof of residence in Montana at the time of birth or proof that
the birth occurred in Montana.
3. One document must show: Proof of Live Birth

The following may be submitted as proof of live birth:

1. A copy of the medical record of the child if he or she was seen shortly after birth by any ofthe
following: physician, registered nurse, nurse practitioner or public health nurse.
2. The laboratory results of the metabolic screening test (PKU). The blood sample must have been
collected within ten days of the birth and forwarded to the laboratory within twenty-four hours
following collection.
3. A notarized affidavit from the mother's employer confirming the dates of her pregnancy or the
fact that she had a live baby recently.
4. A notarized affidavit by a public official that confirms the live birth of the child to this mother.
The public official must have personal knowledge of the live birth.
5. Insurance policy that identifies the child's date and place of live birth.
6. The child's certified blessing or baptismal certificate. The blessing or baptismal certificate must
either have a raised seal of the church or be accompanied by a notarized statement from the
church minister or other church official.

The following may be submitted as proof of pregnancy:

1. Copy of mother’s pregnancy lab tests

2. Copy of ultrasound
3. Copy of doctor record of pregnancy visits
4. A copy of the mother's prenatal or postnatal medical care record, signed by the person
completing the record if not a hospital or clinic.
These should have mother’s name, date of service, name of lab, Hospital, or clinic.

Form A (page 1 of 4)

Questions concerning this form? Please contact us at (406) 444-2685

The following documents (listing street address or rural route) may be submitted as proof of
residence:
1. Utility service or telephone statements at the time of the child's birth.
2. Bank statement at the time of the child's birth.
3. Social service records at the time of the child's birth if parent(s) or child were receiving
public assistance (e.g. WIC, Food Stamps, Medicaid), or child support records
4. Mail- Personalized delivery through the U.S. Postal Service and cancelled by said agency.
This must be postmarked at or near time of child's birth.
5. Rent or mortgage receipts at the time of the child's birth; a notarized statement from the
landlord may also be required.

Note: Other documents may be accepted as proof of birth or proof of residence at the discretion of
the State Registrar.

CERTIFIER INFORMATION/ATTENDANT INFORMATION ON HOMEBIRTH WORKSHEET

CERTIFICATION STATEMENT AND SIGNATURE:

A signature of the certifier is required. The Certifier is the person that was present during birth and
can attest that the child was born alive at the place and time and date as stated. If only the mother
was present at the delivery, the mother can sign as the certifier.

CERTIFIER - NAME & TITLE:

Print the name and title of the person whose signature appears as certifier and specify the title of
certifier: i.e., father, relative, owner of premises, etc.

These are legal items indicating that the facts of birth are correct. They add authenticity to the document
and indicate who delivered the baby. The mailing address of the certifier is needed for possible questions
concerning the birth.

DATE SIGNED (Month, Day, Year)

Print the date the certifier signed the certificate.

ATTENDANT’S NAME, TITLE

Print the name and title of the person that delivered the baby i.e., father, relative, owner of premises,
etc.

Form A (page 2 of 4)
 Was Mother Married at Conception, Birth or Anytime between?

□ Yes □ No

Check “YES” if you are married or were married at conception, birth or any time between.
This would also include, if your child was born and you were married at the time of birth, or
had been married to your husband within 10 months of the birth or 300 days of the birth.
Continue to question “Was Mother Married to the Father?” Refer to Montana Code
Annotated 40-6- 105 (1)(A) MCA

Check “NO” if you are not married or were not married at conception, birth or any time
between. Continue to question “Will Father sign Paternity Acknowledgement?” 50-15-
221 (7)(b) MCA

Was Mother Married to the Father?

□ Yes □ No

Check “YES” if married to the Father, print the name of your husband on the worksheet.
Skip questions “Will Husband sign Non-Paternity Affidavit?” and “Will Father sign
Paternity Affidavit?”

Check “NO” if not married to the Father. Continue to question “Will Husband Sign Non-
Paternity affidavit?”

Will Husband Sign Non-Paternity Affidavit?

□ Yes □ No

Check “YES”, both the mother and husband must fill out, sign and have notarized Affidavit
of Non-Paternity. This form must be included with Homebirth Worksheet. Continue
to “Will Father Sign Paternity Affidavit?” 50-15-221 (7)(a) (ii) (iii) MCA

Check “NO”, print husband’s name in the “Father’s” Information. Refer to 50-15-221
(7)(A) (i)(ii)(iii) MCA

Form A (page 3 of 4)
Will Father sign Paternity Affidavit?

□ Yes □ No

Check “YES”. A Paternity Acknowledgment must be filled out by both parents and signed
in front of a notary public, in order to fill in the Father’s information on the worksheet. The
Paternity Acknowledgment MUST be sent in with the Homebirth Worksheet. The birth
certificate will not be filed if the Paternity Acknowledgement is not received with the
Homebirth Worksheet. Refer to MCA 40-6-105 Section 1E. If you wish to withdraw this
Acknowledgement, you must do so within 60 days, or before a support or paternity order for
the child is entered, whichever is earlier. Refer to MCA 40-6-105 Section 5A.

Check “NO”, Please do not fill in “Father’s Information on Homebirth Worksheet. Refer to
MCA 50-15-221 (7)(b) (c) (d)

If you have any further questions please contact the Office of Vital Records:

Paternity Acknowledgement Questions:

Cheryl Ricker 406-444-1986

Affidavit of Non-Paternity Questions:

Mary Suptic 406-444-4226

Notice of Withdrawal of Paternity Questions:

Mary Suptic 406-444-4226

Questions about filling out Homebirth Worksheet

Melody Lee 406-444-0693

Birth certificates are not automatically issued once the Homebirth Worksheet has been
received by the State of Montana Office of Vital Records. To obtain a Certified Copy of
Birth Certificate after the Homebirth Worksheet is filed, you may contact the Issuance
Section.

Issuance Section 406-444-2685

Certified copies $12.00 each

Form A (page 4 of 4)
 HOME BIRTH WORKSHEET Parent Contact Information -Phone:________________________________
Email Address:________________________________

CHILD’S NAME (First) (Middle) (Last and Suffix if applicable) DATE OF BIRTH SEX

I
FACILITY-NAME (If not institution, give street and number CITY OR LOCATION OF BIRTH COUNTY OF BIRTH TIME OF BIRTH

PLACE OF BIRTH:
Home birth: planned to deliver at home? □Yes □ No □ Other (Specify)_____________________

I certify that this child was born alive at the place and DATE SIGNED ATTENDANT’S NAME, TITLE and NPI
Time and on the date stated (If other than certifier)
Signature NPI__________
CERTIFIER’S NAME AND TITLE MAILING ADDRESS (Street Number or Rural Route Number, City or Town, State, Zip Code)

MOTHER ‘S FULL MAIDEN NAME (First, Middle, Maiden Last Name) BIRTHPLACE (State or Foreign County) DATE OF BIRTH (Month, Day, Year)

I
Does Mother live on a Reservation: □ Yes □ No If yes list what reservation:______________________________________
RESIDENCE – STATE COUNTY CITY OR TOWN, AND ZIP CODE STREET AND NUMBER INSIDE CITY LIMITS

I
FATHER’S CURRENT LEGAL NAME (First, Middle, Last) BIRTHPLACE (State or Foreign County) DATE OF BIRTH (Month, Day, Year)

I I
Does Father live on a Reservation: □ Yes □ No If yes list what reservation:______________________________________
I certify that the personal information provided on this certificate is correct to the best MOTHER’S MAILING ADDRESS
Of my knowledge and belief (If same as residence, enter Zip code Only)

Signature of Parent or Other Informant

Permission is given to provide Social Security Administration with information from this certificate to obtain a Social Security card for this child?

□ Yes □ No Signature of Parent:

Consent to be notified of available health services? □ Yes □ No
CONSENT OBTAINED for INCLUSION in the MONTANA IMMUNIZATION INFORMATION SYSTEM? □ Yes □ No □ Unknown
MOTHER’S EDUCATION (Specify only the highest diploma MOTHER OF HISPANIC ORIGIN? Check the box MOTHER’S RACE (Check one or more races to indicate what the mother
or degree received) that best describes whether the mother is Spanish/Hispanic/ considers herself to be)
Latino. Check the “No” box if the mother is not Spanish/
□ 8th grade or less Hispanic/Latino. White Korean
9th-12th grade: No Diploma □ □
□ □ Black or African American □ Vietnamese
□ High School graduate or GED completed
Some college but no Degree □ No, not Spanish/Hispanic/Latino □ Native Hawaiian □ Samoan
□ □ Yes, Mexican, Mexican American, Chicano □ Asian Indian □ Other Asian (Specify)
□ Associates Degree (e.g. AA, AS)
Bachelor’s Degree (e.g. BA, AB, BS) □ Yes, Puerto Rican □ Chinese ______________
□ □ Yes, Cuban □ Filipino □ Other Pacific Islander
□ Master’s Degree (e.g. MA, MS, MEng,
Med, MSW, MBA) □ Yes, other Spanish/Hispanic/Latino □ Japanese (Specify)_______
(Specify)____________________ Guamanian or Chamorro
□ □ American Indian or Alaska Native
□ Doctorate (e.g. PhD, EdD) or Professional Degree (Name of the enrolled or principal tribe)
(e.g. MD, DDS, DVM, LLB, JD ______________
□ Other (Specify) _______________
FATHER’S EDUCATION (Specify only the highest diploma FATHER OF HISPANIC ORIGIN? Check the box FATHER’S RACE (Check one or more races to indicate what the father
or degree received) that best describes whether the father is Spanish/Hispanic/ considers himself to be)
Latino. Check the “No” box if the father is not Spanish/
□ 8th grade or less Hispanic/Latino. White
9th-12th grade: No Diploma □ □ Korean
□ □ Black or African American □ Vietnamese
□ High School graduate or GED completed No, not Spanish/Hispanic/Latino Native Hawaiian
Some college but no Degree □ □ □ Samoan
□ □ Yes, Mexican, Mexican American, Chicano
□ Asian Indian □ Other Asian (Specify)
□ Associates Degree (e.g. AA, AS) Yes, Puerto Rican Chinese ______________
Bachelor’s Degree (e.g. BA, AB, BS) □ □
□ □ Yes, Cuban
□ Filipino □ Other Pacific Islander
□ Master’s Degree (e.g. MA, MS, MEng, Yes, other Spanish/Hispanic/Latino Japanese (Specify)_______
Med, MSW, MBA) □ □
(Specify)____________________ Guamanian or Chamorro
□ □ American Indian or Alaska Native
□ Doctorate (e.g. PhD, EdD) or Professional Degree (Name of the enrolled or principal tribe)
(e.g. MD, DDS, DVM, LLB, JD ______________
□ Other (Specify) _______________
Was Mother Ever Married Was Mother Married at Conception, Was Mother Married to the Father? Will Husband Sign Non-Paternity Will Father sign Paternity Affidavit?

□ Yes No □
MOTHER’S SOCIAL SECURITY NUMBER:
I□
Birth or Anytime between?
Yes □ No I□ Yes □ No i Affidavit?
□
Yes
FATHER’S SOCIAL SECURITY NUMBER:
□ No I□ Yes □ No

PRINCIPAL OF PAYMENT FOR DELIVERY: DATE OF LAST NORMAL MENSES BEGAN DID MOTHER GET WIC FOOD DURING PREGNANCY?
□Private insurance □ Medicaid □ Self-pay (Month, Day, Year)
□Yes □ No
□ Other (Specify)________________

Form B (page 1 of 2)
 HOME BIRTH WORKSHEET CONTINUED
NUMBER OF PREVIOUS NUMBER OF OTHER DATE OF FIRST PRENATAL CARE ViSIT DATE OF LAST PRENATAL CARE TOTAL NUMBER OF
LIVE BIRTHS
(Do not include this child)
PREGNANCY OUTCOMES
(Spontaneous & induced losses
(mm,dd,yyyy) or □ No prenatal care
VISIT (mm,dd,yyyy) PRENATAL VISITS-
(If none, enter “0”)
or ectopic pregnancies)
Now Living Now Dead Other Outcomes BIRTH WEIGHT (grams preferred, specify Unit) OBSTETRIC ESTIMATE OF GESTATION PLURALITY—Single, Twin
Number___ □ None Number___ □ None Number_____ □ None (Completed weeks) Triplet, etc. (Specify)

I
DATE OF LAST LIVE BIRTH (mm,yyyy) DATE OF LAST OTHER IS INFANT BEING BREASTFED AT IF NOT SINGLE BIRTH –Born First, IS INFANT LIVING AT TIME
PREGNANCY OUTCOME (mm,yyyy) DISCHARGE? Second, Third, Etc. (Specify) OF REPORT
□ Yes □ No □ Yes □No
APGAR SCORE MOTHER TRANSFERRED FOR MATERNAL MEDICAL OR FETAL INFANT TRANSFERRED WITHIN 24 HOURS OF DELIVERY
5 Minute 10 Minutes INDICATIONS FOR DELIVERY? □Yes □ No If yes, enter name of
If yes, enter name of facility transferred to:
facility transferred from: □ Yes □ No
I
CIGARETTE SMOKING BEFORE AND DURING PREGNANCY Average number of cigarettes or packs of cigarettes smoked per day. Alcohol use during pregnancy
For each time period, enter either the number of cigarettes or the # of cigarettes # of packs □ Yes □ No
Number of packs of cigarettes smoked. IF NONE, ENTER”0”. Three Months Before Pregnancy ___________ OR _____________ If yes, average number of drinks per week
First Three Months of Pregnancy ___________ OR _____________
Second Three Months of Pregnancy ___________ OR _____________ _______________
Third Trimester of Pregnancy ___________ OR _____________

MOTHER’S HEIGHT _____________(feet//inches) MOTHER’S PREPREGNANCY WEIGHT _____________(pounds) MOTHER’S WEIGHT AT DELIVERY ______________(pounds)

HEP B VACCINATION INFORMATION – INFANT HEP B TESTING INFORMATION- MOTHER

Hep B Birth Dose Given □ Yes □ No □ Parent Refused □ Unknown Hep B Administration Date: (mm,dd,yyyy) Time: am / pm
HBsAg Test Date: (mm,dd,yyyy) _________________ HBsAg Test Result □ Positive-Reactive □ Negative-Nonreactive □ Unknown

CONSENT OBTAINED for INCLUSION in the MONTANA IMMUNIZATION INFORMATION SYSTEM? □ Yes □ No □ Unknown
ABNORMAL CONDITIONS OF THE NEWBORN (Check all that apply) CONGENITAL ANOMALIES OF THE NEWBORN (Check all that apply)
□ Assisted ventilation required immediately following delivery □ Anencephaly □ Meningomyelocele/Spina bifida
□ Assisted ventilation required for more than six hours □ Cyanotic congenital heart disease □ Congenital diaphragmatic hernia
□ NICU admission □ Omphalocele □ Gastroschisis
□ Newborn given surfactant replacement therapy □ Limb reduction defect (excluding congenital amputation and dwarfing syndromes)
□ Antibiotics received by the newborn for suspected neonatal sepsis □ Cleft Lip with or without Cleft palate □ Cleft Palate alone
□ Seizure or serious neurologic dysfunction □ Down Syndrome □ Suspected Chromosomal disorder
□ Significant birth injury (skeletal fracture(s), peripheral nerve injury, and /or soft tissue/solid organ □ Karyotype confirmed □ Karyotype confirmed
hemorrhage which requires intervention □ Karyotype pending □ Karyotype pending
□ None of the above □ Hypospadias □ None of the anomalies listed above

MEDICAL RISK FACTORS FOR THIS PREGNANCY OBSTETRIC PROCEDURES (Check all that apply) METHOD OF DELIVERY
(Check all that apply) □ Cervical cerciage
Diabetes □ Tocolysis A. Was delivery with forceps attempted but unsuccessful?
□ Prepregnancy (Diagnosis prior to this pregnancy) □ Yes □ No
□ Gestational (Diagnosis during this pregnancy) External cephalic version:
□ Successful B. Was delivery with vacuum extraction attempted but
Hypertension □ Failed unsuccessful?
□ Prepregnancy (Chronic) □ None of the above □ Yes □ No
□ Gestational (PIH, Preeclampsia)
□ Eclampsia C. Fetal presentation at birth
□ Previous preterm birth ONSET OF LABOR (Check all that apply) □ Cephalic □ Breech □ Other
□ Other previous poor pregnancy outcome
(Includes Perinatal death, small for gestational age Premature Rupture of the Membranes (prolonged,>12 D. Final route and method of delivery (Check one)
intrauterine growth restricted birth)
□
Precipitous Labor (<3 hrs.)
- hrs.)
□
□ Pregnancy resulltfrom infertility treatment-if yes, Prolonged Labor (>20 hrs.) □ Vaginal/Spontaneous
check all that apply
□ - Vaginal/Forceps
□ None of the above □
□ Fertility-enhancing drugs, Artificial insemination or □ Vaginal/Vacuum
Intrauterine insemination □ Cesarean
□ Assisted reproductive technology (e.g., in vetro Fertilization
(IVF), gamete intrafallopian transfer (GIFT) If cesarean, was a trial of labor attempted?
□ Mother had a previous cesarean delivery □ Yes
If yes, how many _____________ □ No
□ None of the above
CHARACTERISTICS OF LABOR AND DELIVERY MATERNAL MORBIDITY (Check all that apply)
(Check all that apply) (Complications associated with labor and delivery)
INFECTIONS PRESENT AND/OR TREATED DURING THIS
PREGNANCY (Check all that apply)
□ Induction of labor
□ Augmentation of labor □ Maternal transfusion

Gonorrhea
□ Non-vertex presentation □ Third or fourth degree perineal laceration
□
Syphilis
□ Steroids (glucocorticoids) for fetal lung maturation □ Ruptured uterus
□ received by the mother prior to delivery □ Unplanned hysterectomy
Chlamydia
□ □ Antibiotics received by the mother during labor □ Admission to intensive care unit
□ Hepatitis B Clinical chorioamnionitis diagnosed during labor or maternal Unplanned operative room procedure following delivery
Hepatitis C
□ □
□ temperature > 38ºC (100.4ºF) □ None of these above
None of the above
-
□ □ Moderate/heavy Meconium staining of the amniotic fluid
□ Fetal intolerance of labor such that one or more of the following
actions was taken: in-utero resuscitative measures, further
fetal assessment, or operative delivery
□ Epidural or spinal anesthesia during labor
□ None of the above

Form B (page 2 of 2)
Questions concerning this form? Please contact us at (406) 444-0693
 MONTANA DEPARTMENT OF PATERNITY
PUBLIC HEALTH & HUMAN SERVICES
VITAL RECORDS & STATISTICS BUREAU ACKNOWLEDGMENT
PO BOX 4210
HELENA, MT 59604-4210

PLEASE PRINT HARD USING A BALL POINT PEN

CHILD'S NAME (First, Middle, Last) DATE OF BIRTH SOCIAL SECURITY NUMBER

CITY OF BIRTH HOMEBIRTH ADDRESS

MOTHER'S NAME (First, Middle, Last (MAIDEN SURNAME)) MOTHER'S DATE OF BIRTH

MOTHER'S STATE OF BIRTH (If Not U.S.A. Give Country) MOTHER'S RACE MOTHER'S SOCIAL SECURITY NUMBER

FATHER'S NAME (First, Middle, Last) FATHER'S RACE FATHER'S DATE OF BIRTH

FATHER'S ANCESTRY Education (Elementary/Secondary) FATHER'S SOCIAL SECURITY NUMBER

(0-12) College (1-4 or 5+)

FATHER'S STATE OF BIRTH (If Not U.S.A. Give Country) FATHER'S OCCUPATION FATHER'S PLACE OF EMPLOYMENT

BOTH PARENTS MUST SIGN BEFORE A NOTARY PUBLIC

We the natural mother and father, declare under penalty of perjury under the laws of the State of Montana that the following statements are true and correct. When
completed and filed with the state registrar this Voluntary Declaration of Paternity establishes a father-child relationship identical to the relationship established when a
child is born to married parents. NOTICE TO BOTH PARENTS: THIS IS A LEGALLY BINDING DOCUMENT. Upon signing this declaration, it becomes your duty under
law to provide support and care for the child as the parent. Do not sign this declaration if you do not understand the legal effect of the document or you have doubts
about the paternity of the child. If you wish to withdraw this Acknowledgement, you must do so within 60 days, or before a support or paternity order for the
child is entered, whichever is earlier.
PLEASE PRINT/SIGN HARD USING A BALL POINT PEN

I certify that I am the natural mother. The above information is true and the man
named above is the only possible father. I make this affidavit to name the natural I certify that the above information is true. I make this affidavit to showthat I am
father on my child's birth certificate. I understandthe rights, responsibilities, the natural father on my child's birth certificate. I also understandthat by
alternatives, and consequences of signing this affidavit. acknowledging paternity of this child, I accept an obligation to provide child
Verification of Signer’s ID is Mandatory support under the laws of the State of Montana. I understand the rights,
responsibilities, alternatives, and consequences of signing this affidavit.
Verification of Signer’s ID is Mandatory
Mother's Signature
Address Father's Signature
City, State, Zip Address
City, State, Zip
Phone Number

State of
County of State of
County of

This document was signed and sworn to (or affirmed) before me

This document was signed and sworn to (or affirmed) before me
on by on by
(Date) (Name of Signer) (Date) (Name of Signer)

(Notary’s Signature) (Notary’s Signature)

[Official Stamp] [Official Stamp]

Form C Questions concerning this form? Please contact us at (406) 444-1986

 Fill this out ONLY if Mother or Father wish to withdraw the signed

Paternity Acknowledgement within 60 days from the date you signed the Paternity
Acknowledgment, or before a support or paternity order for the child is entered,
whichever is earlier.

STATE OF MONTANA
DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES
OFFICE OF VITAL RECORDS

NOTICE OF WITHDRAWAL OF PATERNITY ACKNOWLEDGMENT

I, , signed an acknowledgment of paternity

(Your name)
for on .
(Child’s name) (Date paternity acknowledgment was signed)

A copy of this notice of withdrawal was provided to me with the paternity acknowledgment form.
Having reconsidered my action signing the acknowledgment, I hereby withdraw, cancel and
rescind my acknowledgment.

I understand that this withdrawal is useless and of no effect unless it is filed with the Montana
Department of Public Health and Human Services within 60 days of the date the paternity
acknowledgment was signed, or before a support or paternity order for the child is entered,
whichever is earlier. I understand that to file this document, I must present it in person to the
department at the address below, or mail it to the department at the mailing address below so that
it is received and available for filing with the department’s vital records before the withdrawal
period ends.

I further certify that I have provided a copy of this notice to the other party who signed the
acknowledgment of paternity.

Signature Date
Verification of Signer’s ID is Mandatory

State of:
County of:

This Document was signed and sworn to (or affirmed) before me on

(Date)
By
(Name of Signer)

(Notary Signature)
[Official Stamp]

INSTRUCTIONS FOR FILING THIS WITHDRAWAL NOTICE

You may file this document:
IN PERSON: BY MAIL:
DPHHS DPHHS
Office of Vital Records Office of Vital Records
111 Sanders St., Rm 6 PO Box 4210
Helena, MT 59620 Helena, MT 59604-4210
 AFFIDAVIT OF NONPATERNITY

I , being duly sworn, deposes and says that: I was married to

Husband's Name

on ______________________in _______________ ,__________.

Wife's Name Date of Marriage City State

My wife gave birth to a child in ,________________________ on

Sex City County

_________________ . The name of the child is

Date of Birth Child’s Name

I now state that although legally married at the time of this birth, I am not the father of the

named child. I request that my name not be listed on the birth certificate.

Husband’s Signature

Street Address

City, State and Zip Code

State of:________________________
County of:______________________

Personally appeared before me and whose identity I proved on the

basis of satisfactory evidence to be the signer of the above instrument.

Subscribed and sworn to before me this day of , 20____.

Printed Name:
Notary Public for the State of:
Residing at:
SEAL My commission expires:

=================================================================================

I, , am the mother of and I state that

Mother's Name Child's Name

I was legally married at the time of the birth. My husband as listed is not the father of the above

named child and I request that his name not be listed on the birth certificate.

Wife’s Signature (Mother)

Street Address

City, State and Zip Code

State of:________________________
County of:______________________

Personally appeared before me and whose identity I proved on the

basis of satisfactory evidence to be the signer of the above instrument.

Subscribed and sworn to before me this day of , 20____.

Printed Name:
Notary Public for the State of:
Residing at:
SEAL My commission expires:

Form E
Questions concerning this form? Please contact us at (406) 444-4226

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