Mississippi Administrative Code
Title 18 - HUMAN SERVICES
Part 6 - Division of Family and Children's Services
Chapter 1 - DFCS Policy Manual
Section 18-6-1-G - Adoption Policy
ADOPTION ASSISTANCE
Section 18-6-1-G-XII - APPENDICES
Appendix 18-6-1-G-XII-C - Form 459A- Mother's Statement Naming Father of Child

STATE OF ___________________

COUNTY OF _________________

THIS DAY personally came and appeared before me, the undersigned Notary Public, in and for the aforesaid jurisdiction the within named ____________________________________ (Mother's full name) who, first having been by me duly sworn, on oath states the following;

That I, _________________________ (Mother's full name), am the biological mother of _______________________________ (Full name of child as on birth certificate), a female/male child born on the ________ day of _______________________, A.D., 20 ________, and that _______________________________ (Name of putative father) is the biological father of said child, whose last address known to me was _________________________ (Street)

_________________________ (City/ State/ Zip)

That ____________________________ (Name of putative father) and I are not now nor have we ever been married.

After having been fully advised that the making of false statement of identity under oath is punishable as perjury, I, the undersigned affiant, state that the matters and fact as herein set forth are true and correct, and I do hereby make this affidavit of my own free will and accord.

_____________________________

Mother's Signature

SWORN TO AND SUBSCRIBED before me on this, the _____________ day of ________________, A.D., 20 ______.

______________________________

Notary Public

My Commission Expires:

____________________