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FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, check one: FORMCHECKBOX  Affidavit of Parentage  FORMCHECKBOX  Court OrderProvide the following information about that document: FORMTEXT      Date SignedPlace Signed (CityCountyState FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      What is your relationship to this child? FORMTEXT      Child TwoChild s Full Name (First, Middle, Last, Suffix)Birth DateSocial Security No.Sex (M or F) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Conception DateConception City and StateBirthplace City and StateWho paid for the birth of the child (Medicaid, Private Insurance, Mother, Father, Other)? FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Has the father completed a document admitting he is the father of the child, such as an Affidavit of Parentage, or is there a court order establishing paternity? FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, check one: FORMCHECKBOX  Affidavit of Parentage  FORMCHECKBOX  Court OrderProvide the following information about that document: FORMTEXT      Date SignedPlace Signed (CityCountyState FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      What is your relationship to this child? FORMTEXT      Child ThreeChild s Full Name (First, Middle, Last, Suffix)Birth DateSocial Security No.Sex (M or F) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Conception DateConception City and StateBirthplace City and StateWho paid for the birth of the child (Medicaid, Private Insurance, Mother, Father, Other)? FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Has the father completed a document admitting he is the father of the child, such as an Affidavit of Parentage, or is there a court order establishing paternity? FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, check one: FORMCHECKBOX  Affidavit of Parentage  FORMCHECKBOX  Court OrderProvide the following information about that document: FORMTEXT      Date SignedPlace Signed (CityCountyState FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      What is your relationship to this child? FORMTEXT      ADDITIONAL INFORMATIONIf you cannot provide information about the parent who is not in the home, such as, date of birth and/or Social Security number, attach a written statement that could assist in identifying and locating the parent. Include the following information in your statement:Authorities: R 400.3009 MAC and R 400.5008 MAC Failure to complete may result in loss of benefits from Child Development and Care (CDC) and the Food Assistance Program (FAP). 42 USC 654(29) Failure to provide information may result in loss of Family Independence Program (FIP) benefits for all family members and loss of Medicaid (MA) for all adult members.How long you have known the parent. Date and type of last contact with the parent. Name(s) of the parent s family members (parents, siblings and/or children).Parent s current or former roommate(s). Parent s former address(es). Parent s current or former spouse(s). Any other information you feel may assist in identifying and locating the parent.I declare that the information provided above is true and correct to the best of my knowledge and agree to report changes in my circumstances that may affect support action in my case.SignatureDate     DHS-842 (Rev. 9-10) Previous edition may be used. 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