WIXLIB

HFS 3416D, DENIAL OF PARENTAGEThe HFS 3416D, Denial of Parentage (Denial), is completed, signed, witnessed and filed with theDepartment of Healthcare and Family Services (HFS) when the biological mother of the child is or wasmarried or in a civil union at the time the child was born or within 300 days before the child was born,and the presumed parent is not the biological father and the biological father acknowledges paternity ofthe child by signing and filing the Voluntary Acknowledgment of Paternity (VAP) with HFS.Individuals are instructed to read all parts of the Denial, including the rights and responsibilities andinstructions on the back of the form, before completing.To lessen any confusion you may have when completing the Denial, a list of parent definitions isprovided below.Definitions of Parents:Biological Father – The biological father is the man who provided the paternal genes ofthe child. The biological father is sometimes referred to as the natural father.Biological Mother – The biological mother is the woman who gave birth to the child.Presumed Parent – A presumed parent is a person married to or in a civil union with thebiological mother when the child is born or if the child is born within 300 days after themarriage or civil union has ended.It is necessary for you to complete all fields as shown in these instructions in order to process this formcorrectly.Field Descriptions#ItemDescriptionCHILD’S INFORMATION AS SHOWN ON BIRTH CERTIFICATE (boxes 1-8)(ALL information must be entered exactly as it appears or will appear on the birth certificate)1Child’s first nameEnter first name (including accent marks,apostrophes and hyphens).If no first name on birth certificate, leave blank.2Child’s middle nameEnter middle name (including accent marks,apostrophes and hyphens).If no middle name on birth certificate, leave blank.3Child’s last nameEnter last name (including hyphens, accent marksand apostrophes).4Suffix following child’s last name If a suffix is not included on birth certificate, leave(Jr. II, III, IV)blank.5Child’s date of birthDate of birth (mm/dd/yy) must match date of birth onthe birth certificate. If date is wrong on the birthcertificate, the mother must contact the hospital orbirthing center to have it corrected.6Child’s genderAppropriate box must be checked.F - femaleM – male7Child’s Place of Birth – HospitalEnter name of hospital or birthing center. If theNamename is longer than the space provided,abbreviations or initials are acceptable.When using initials or the abbreviated name, includethe street address.

8Child’s city/county/state of birthEnter the city, county, and state where the birthingcenter or hospital is located. If not born in a medicalfacility, enter city, county, and state where the birthactually occurred.PRESUMED PARENT INFORMATION (boxes 9 – 14)Presumed Parent – A person married to or in a civil union with the biological mother, or if thechild is born within 300 days after the marriage or civil union has ended.9Full name of presumed parentEnter the first, middle and last name.10 Place of birth of presumed parent Enter city and state where born; if not born in theUnited States, enter the name of the country.11 Date of birth of presumed parent Enter date of birth (mm/dd/yy)12 Social Security Number ofEnter the nine digit social security number. If nopresumed parentsocial security number, enter taxpayer identificationnumber. If neither, leave blank.13 Address of presumed parentEnter complete current address.14 City/State/Zip Code of presumed Enter the City, State and Zip Code.parent15 Daytime phone of presumedEnter the daytime phone number of presumedparentparent including area codeBIOLOGICAL MOTHER INFORMATION (boxes 16 – 24)16 Full name of biological motherEnter the first, middle and last name.17 Maiden name of biologicalEnter maiden name, if different from current lastmothername.18 Place of birth of biological mother Enter city and state where born; if not born in theUnited States, enter the name of the country.19 Date of birth of biological mother Enter date of birth (mm/dd/yy)20 Social Security Number ofEnter the nine digit social security number. If nobiological mothersocial security number, enter taxpayer identificationnumber. If neither, leave blank.21 Address of biological motherEnter complete current address.22 City/State/Zip Code of biologicalEnter the City, State and Zip Code.mother23 Daytime phone of biologicalEnter the daytime phone number of biologicalmothermother including area code24 Date of marriage or civil unionEnter date of marriage or civil union of biologicalmother and presumed parent.PRESUMED PARENT AND WITNESS SIGNATURE INFORMATION (Boxes 25 – 30)Witness - Must be an adult age eighteen or older but cannot be a person named on the form.25 Signature line for presumedSignature of the presumed parent.parentBefore signing: Read and understand theparagraph above the signature line.26 Printed name of witnessWitness is to print his/her name.27 Signature line for witnessSignature of witness.28 Address of witnessWitness is to enter his/her full address.29 Phone number for witnessWitness is to enter his/her contact number.30 Date parties signedDate presumed parent and witness signed Denial.BIOLOGICAL MOTHER AND WITNESS SIGNATURE INFORMATION (boxes 31 – 36)Witness - Must be an adult age eighteen or older but cannot be a person named on the form.31 Signature line for biologicalSignature of the biological mother.

mother3233343536Printed name of witnessSignature line for witnessAddress of witnessPhone number for witnessDate parties signedBefore signing: Read and understand theparagraph above the signature line.Witness is to print his/her name.Signature of witness.Witness is to enter his/her full address.Witness is to enter his/her contact number.Date biological mother and witness signed Denial.

File Date for ACU use onlyIllinois Denial of ParentagePLEASE READ ALL PARTS OF THIS FORM INCLUDING YOUR RIGHTS AND RESPONSIBILITIES ANDINSTRUCTIONS ON THE OTHER SIDE BEFORE COMPLETING THE FOLLOWING INFORMATION. ALLITEMS MUST BE ANSWERED.Child’s Information as shown on or will be shown on Birth CertificateChild’s Name (First)1Middle (if any)Print all requested informationLast (same as on birth certificate)Name of Hospital or Address of Place of Birth73Suffix (Jr, II, III) 4City, County, and State of Birth8ODate of Birth (mm/dd/yy) Gender 65MF2nlyTHIS FORM IS TO BE USED ONLY BY PARTIES WHO ARE OR WERE MARRIED OR IN A CIVIL UNIONWHEN THE CHILD WAS BORN; OR THE MARRIAGE OR CIVIL UNION WAS LEGALLY TERMINATED WITHIN300 DAYS OF THE DATE THE CHILD WAS BORN.Presumed Parent - Person married to or in a civil union with the biological mother when the child is born or if the child is born within 300 days after themarriage or civil union has ended.Presumed Parent’s Name (first)9Middle (if any)9Last9Suffix (Jr, II, III)Address (street address and/or PO box)1013Biological Mother’s Name (First)16City, State, and ZipMiddle (if any) 1614Current Last Name1821Date of Marriage or Civil Union24rmAddress (street address and/or PO box)City, State, and ZipSSN/TIN2212Daytime Phone (include area code) 15Maiden Name (before 1st marriage)1716Date of Birth (mm/dd/yy)atPlace of Birth (city, state or foreign country address)Date of Birth (mm/dd/yy) 11ionPlace of Birth (city, state or foreign country address)19SSN/TIN20Daytime Phone (include area code)23By signing I acknowledge that I have read the rights and responsibilities and instructions on the other side of this form and understand myrights and responsibilities created and waived by signing this form.I UNDERSTAND THAT I CAN REQUEST A GENETIC TEST REGARDING THE CHILD’S PATERNITY. BY SIGNING THISFORM I GIVE UP MY RIGHT TO A GENETIC TEST.Each person must sign and date this form in the presence of a witness age 18 or older. The witness must not be a person named on this form.BIOLOGICAL MOTHER: Under the penalties of perjury provided bySection 1-109 of the Illinois Code of Civil Procedure, I certify that mystatements in this document are true and correct.Presumed Parent’s Signature25Biological Mother’s Signature31Witness InformationPrinted Name26Witness InformationPrinted e Number29Phone Number35Date Parties Signed30Date Parties Signed36InfoPRESUMED PARENT: Under the penalties of perjury provided bySection 1-109 of the Illinois Code of Civil Procedure, I certify that mystatements in this document are true and correctHFS 3416D (R-4-17) To request a certified copy of the Denial go to www.childsupport.illinois.gov and complete and follow instructions on HFS 3416H,Request for a Certified copy of the Voluntary Acknowledgment of Paternity and/or Denial of Parentage.For Official Use OnlyCase #Docket #CP RINNCP RIN