How do I offer parents an opportunity to sign the Paternity Acknowledgment?

Follow the six steps.

These instructions assume that a parent gives birth in a hospital, birthing clinic or at home. Sometimes, however, you will have opportunity to simply give information about the program to parents who are expecting to give birth weeks or months in the future. You may give out the Paternity Acknowledgment and booklets, and show the video (English) (Spanish).

Encourage the parents to bring the acknowledgment to the place where they will give birth.

Step 1

Determine whether or not the parents are married to each other.

If parents are not married to each other:

  • Give the parents a Paternity Acknowledgment (DOH/CHS 021) and a copy of the DSHS booklet entitled "Establish Parentage for Your Child's Sake" (DSHS 22-586). The Paternity Acknowledgment and booklet are available in English and Spanish.
  • Ask parents to read the instruction page on the front of the acknowledgment and the Statement of Rights and Responsibilities on the back of the acknowledgment. Federal and State laws require us to provide parents this written information.

Step 2

Federal and state laws also require that parents be given oral information. Parents should not sign the Paternity Acknowledgment until they have received this information. Offer the parents the opportunity to do at least one of the following:

  • View a short video which explains the benefits and legal requirements of signing the acknowledgment. The video is available in English and Spanish (English) (Spanish). Or,
  • Ask the parents to call 1-800-356-04631-800-356-04631-800-356-0463 for more information.
  • You may read the instruction page and the legal information to the parents.

Step 3

Help parents complete the Paternity Acknowledgment. Verify that it is filled out completely and accurately. Check carefully the following lines on the acknowledgment:

  • Line 12: The mother must check either yes or no. If she checks yes, she must provide the person's name. In addition, be certain that her husband or registered domestic partner also completes and has notarized the Presumed Parent's Denial of Paternity on lines 42 - 48. DOH cannot accept an acknowledgment with the YES box on item 12 unless the husband or domestic partner completes the Presumed Parent's Denial of Paternity.
  • Line 31: Federal regulations require providers to attempt to gather the father's social security number. Sometimes a foreign national will not have one. You may leave line 31 blank if the father will not provide his social security number or if he does not have one.
  • Line 39: The father must check either yes or no to the first question. If the father answers "No" to the first question, he should leave the second question blank. If the father asks for further information or genetic testing, refer him to the "Establish Parentage for Your Child's Sake" booklet and to the Statement of Rights and Responsibilities on the back of the Paternity Acknowledgment.
  • Line 40 and 41: Both parents must sign in the presence of a notary. The notary must attest to the authenticity of the signature being made.

Step 4

Notarize the parent's signatures on lines 40 and 41. Be certain to separately notarize each signature and place a notary stamp or seal to the right of both the mother's and father's signature block. Sometimes notary services are not immediately available at the place of birth. If possible, help the parents find a place where they may receive notary services. The bottom of the instruction page of the acknowledgment lists some potential notary locations. Any Washington State Division of Child Support (DCS) office will notarize the acknowledgment without cost. Some parents will want to take the acknowledgment home with them. The parents must complete and return the notarized acknowledgment to you within 5 days of the birth. Remind them that if they return the completed acknowledgment to you before you send the birth certificate to DOH, you will forward the acknowledgment to DOH for filing. If parents do not return the completed acknowledgment within five days, they can choose one of the following options:

  • " Mail the acknowledgment to DOH with the filing fee. The address is P.O. Box 47814, Olympia, WA 98504-7814 Or,
  • Take the complete acknowledgment to the local DCS office. DCS will notarize the acknowledgment without charge and forward it to DOH. DCS will pay the fee for the parents.

Step 5

Distribute copies to the appropriate people and places as follows:

  • Mail the original (white) to the DOH, Center for the Health Statistics (CHS), P.O. Box 47814, Olympia, WA 98504-7814 at the same time you submit the birth certificate information. If the mother is married or in a registered domestic partnership and the husband or domestic partner has signed a denial, include the denial with the acknowledgment.
  • Send the pink copy to the Division of Child Support (DCS). *See Step 6 for instructions.
  • Give the yellow copy to the mother.
  • Give the green copy to the father.

Step 6

The Washington State Division of Child Support (DCS) will pay you $20 for each correctly completed and notarized acknowledgment. Complete the State of Washington Invoice Voucher (Form DSHS A19-1A) PDFWord Document

  • In the Vendor or Claimant section (Top left), type the official name (not the DBA name) and address of the hospital, person, or organization which should receive payment.
  • Assign an invoice number or unique identifier and date in the upper right hand corner. This will assist your fiscal/accounting department when they receive payment from DSHS.
  • An authorized person must sign the invoice (top right). Include the phone number and the date signed. The invoice is considered incomplete without this information.
  • You may batch several acknowledgments with one invoice (preferred method). Each invoice provides space for up to 30 names that correspond to the acknowledgments you attach. If you submit 30 or less acknowledgments, list each name on the invoice. If you submit more than 30 acknowledgments, you may attach a separate list of names.
  • In the Date column enter the child's date of birth.
  • In the Child's full name column enter the child's full name.
  • Multiply the Quantity times $20 and enter the total in the Total due column.
  • Leave all other parts of the invoice voucher form blank.
  • Attach the pink copies of the acknowledgments to the invoice.

Mail the completed invoice voucher and the pink acknowledgment copies to:

DSHS/ESA Finance/Accounting Unit
PO Box 45445
Olympia, WA 98504-5445