Center for Health Statistics
P.O. Box 9709
Olympia, WA 98507
360-236-4300
Fees: $18 Filing Fee
ACKNOWLEDGMENT OF PARENTAGE
THIS IS A LEGAL DOCUMENT
DOH 422-159 March 2021 COMPLETE IN INK AND DO NOT ALTER
READ THE INSTRUCTIONS CAREFULLY ON PAGES 3 & 4. ITEMS 1-29 ARE REQUIRED.
Only check this box if another person will be denying parentage. (See page 4 for more information)
If checked, provide the full name of the individual denying parentage:
What parent labels would you like displayed on the birth certificate? (If not selected, the default is Mother/Father)
Mother/Father Parent/Parent
CHILD
1. Child’s First Name
2. Middle Name
3. Last Name
4. City or County of Birth
6. Place of Birth – Name of hospital or location where child was born
BIRTH PARENT
/MOTHER
7. Birth Parent’s (Mother) First Name
8. Middle Name
9. Last Name as it appears on your birth certificate
10. Date of Birth (MM/DD/YYYY)
12. Telephone
( )
13. Email
14. Street Address
15. City
16. State
17. Zip
PARENT
/FATHER
18. Parent/Father’s First Name
19. Middle Name
20. Current Legal Last Name
21. Date of Birth (MM/DD/YYYY)
22. Birthplace (State, or Territory/Foreign Country)
23. Social Security Number
24. Telephone
( )
25. Email
26. Street Address
27. City
28. State
29. Zip
Each party must sign this acknowledgment in the presence of either a notarial officer OR third party witness, not both. All fields are
required, except for the notarial appointment expiration date when signed by a third party witness.
Each party declares under penalty of perjury under the laws of the state of Washington that they have been provided with and understand the
rights and responsibilities, as written on the back of this form, and that the information they have provided is true and correct. Each party
affirms that no other individual can legally claim parentage of the child and accepts the responsibility to provide child support as determined
by applicable law.
Birth parent’s (Mother) signature___________________________________________
Signed and sworn before me on ______________ by__________________________
Date (MM/DD/YYYY) Print Full Name of Birth Parent (Mother)
State of ___________________________, County of _________________________
______________________________________, _____________________________
Signature of Witness or Notarial Officer Title of Office (if Notary)
_______________________________ My commission expires __________________
Printed Full Name of Witness or Notarial Officer Notary Use Only
Parent/Father’s signature________________________________________________
Signed and sworn before me on ______________ by__________________________
Date (MM/DD/YYYY)
Print Full Name of Parent/Father
State of ___________________________, County of __________________________
______________________________________, ______________________________
Signature of Witness or Notarial Officer Title of Office (if Notary)
_______________________________ My commission expires __________________
Printed Full Name of Witness or Notarial Officer Notary Use Only
Place notary
seal here
Place notary
seal here
Center for Health Statistics
P.O. Box 9709
Olympia, WA 98507
360-236-4300
Fees: $18 Filing Fee
THIS IS A LEGAL DOCUMENT
Page 2 of 4
DOH 422-159 March 2021
STATEMENTS OF ACKNOWLEDGMENT
By signing this form, you declare under penalty of perjury under the laws of Washington State that you understand the
following:
− The Acknowledgment of Parentage (AOP) is a legally binding form. The legal basis for this form are chapters 26.26A
and 26.26B of the Revised Code of Washington (RCW).
− This form is voluntary and does not require a court proceeding. Alternatively, you may choose to establish parentage
through state or tribal court.
− You have the right to talk with an attorney before signing this form. If you do not understand this information or have
further questions, you should talk to an attorney.
− You have received oral information about your rights and responsibilities by doing one of the following: (1) watched a
video, (2) listened to a phone message by calling 1-800-356-0463, or (3) speaking with a hospital employee or
attorney.
− Once the AOP is signed and filed with Department of Health, Center for Health Statistics, the parent’s name will be
added to the child’s birth record (RCW 26.26A.200 and 26.26A.215).
− Once the AOP is signed, both parents will be legally responsible for financially supporting this child.
− If you are not sure that you are the parent of the child and the child resides in Washington State, you may open a
child support case with the Division of Child Support (DCS). In most cases, you will be required to submit to genetic
tests to decide parentage. The genetic parent may be responsible for the costs of the test. To locate the DCS office
nearest to you, call 1-800-442-5437. You can find additional information about parentage establishment in the booklet
entitled “Establish Parentage for Your Child’s Sake.” It is available at hospitals, birthing centers, and DCS offices
(RCW 26.26A.300 through 26.26A.515).
− Both parties affirm that no other individual can legally claim parentage for this child. If there is an individual that is an
alleged genetic parent or presumed parent and does not file a Denial of Parentage (DOP), this AOP is void.
− Any individual who signed an AOP or Denial of Parentage (DOP) may change their mind and rescind (which means to
revoke or cancel). To rescind, a Rescission of Parentage form must be filed with the Department of Health, Center for
Health Statistics within a maximum of 60 days after the AOP or DOP is filed or before the first court proceeding,
which ever happens first (RCW 26.26A.235).
− A challenge to either an AOP or a DOP after the period for rescission has passed is permitted only for limited reasons
including fraud, duress, or factual mistake. It must be brought to Superior Court and the challenger has the burden of
proof. A challenge must be brought within 4 years from the date the AOP is filed with the Department of Health,
Center for Health Statistics (RCW 26.26A.235 through 26.26A.245).
− Only a court may determine custody and visitation issues for the child. Either parent may ask Superior Court to make
residential provisions or a parenting plan after the 60-day rescission period has elapsed. The court may require the
parent to pay costs (RCW 26.26A.400 through 26.26A.515).
− For the purpose of this form, “witnessed” means at least one individual who is authorized to sign has signed a record
to verify that the individual personally observed a signatory sign the record (RCW 26.26A.010(23)). A person signing
the witnessed statement must be at least 18 years of age and not related by blood or marriage to the individuals who
sign a voluntary acknowledgment of parentage, denial of parentage, or rescission of parentage form.
− “Notarial officer” means a notary public or other individual authorized to perform a notarial act (RCW 42.42.010(9)).
Center for Health Statistics
P.O. Box 9709
Olympia, WA 98507
360-236-4300
Fees: $18 Filing Fee
THIS IS A LEGAL DOCUMENT
Page 3 of 4
DOH 422-159 March 2021
INSTRUCTIONS FOR ACKNOWLEDGMENT OF PARENTAGE FORM
Each parent should carefully read these instructions before completing and signing the Acknowledgment of Parentage (AOP)
form. The AOP must be either notarized or witnessed by a third party, not both, to be filed with the Department of Health,
Center for Health Statistics. We cannot file forms with missing information and will return the forms to the birth
parent/mother.
Instructions for completing the AOP:
Each parent must sign page 1 in the presence of a notary or third party witness.
The third party witness or notary must sign, print their name, and date on page 1.
Submit completed AOP with a non-refundable $18 check or money order payable to DOH.
(No payment is required when parents return this AOP to the hospital within 5 days of birth. The hospital must
submit the AOP within 10 days to DOH.)
If you want to order a birth certificate with both parents listed, you must submit a Certificate Order Form
and all
required documents referenced on the Certificate Order form instructions page, as well as a $25 check or money
order payable to DOH.
Send all forms and payments to:
Department of Health
Center for Health Statistics
PO Box 9709
Olympia, WA 98507
What is an AOP? An AOP is a legal form used to add a second parent to a child’s birth certificate. By filing this form, you
establish a parent – child relationship or “parentage.”
When can an AOP be used? An AOP can only be used if:
− Everyone agrees,
− No other person claims to be the parent of the child.
Who can Sign an AOP? An AOP must be signed by the mother/birth parent and the second parent/father of the child. You
and the mother/birth parent of the child can use the AOP form if any of the following situations apply:
− If you are the genetic father/parent of the child, but have never married the mother/birth parent.
− If you are or were married to the mother/birth parent anytime during the pregnancy, but are not listed on the birth
certificate.
− If you married the mother/birth parent after the child was born.
− If you lived in the same household with the child for the first 4 years of their life and consider the child as your own.
− If you and the mother/birth parent conceived the child through assisted reproduction.
Do I need a notary or a witness? Yes. Each parent must choose to sign the AOP in front of either a notary OR a witness.
The notary or witness must also complete the signature block. Common notary locations include hospitals, local banks, title
companies, and attorneys/county clerks. A person signing the witnessed statement must be at least 18 years of age and not
related by blood or marriage to the individuals who sign an AOP form. The local child support offices will serve as witnesses.
Center for Health Statistics staff will not serve as witnesses.
How do I change my child’s last name?
You have 1 year from the date the AOP is filed to submit an Affidavit for Correction form to change your child’s last name. You
can change it to either parents’ name on the AOP, any combination of either parents’ last names, or hyphenated. You can
only make this change once. Both parents listed on the AOP must sign the form. You can send the Affidavit for Correction
form separately or together with an AOP form to the Department of Health. There is no additional fee. If the child is 18 years
or older, a court order is required to change the child’s name.
Center for Health Statistics
P.O. Box 9709
Olympia, WA 98507
360-236-4300
Fees: $18 Filing Fee
THIS IS A LEGAL DOCUMENT
Page 4 of 4
DOH 422-159 March 2021
Denying Parentage Checkbox
Only check this box if another person, an alleged genetic parent or presumed parent, is denying parentage. If checked, the
alleged genetic parent or presumed parent denying parentage must submit a Denial of Parentage form (DOP). The form can
be signed by:
− The spouse or ex-spouse who is or was married to the birth parent/mother and will not be the parent listed on the
child’s birth certificate.
− A person who is genetically related to the child and is revoking their right to be a parent listed on the child’s birth
certificate.
− The second parent listed on the child’s birth certificate. An AOP form must be submitted to replace the second parent
being removed.
The AOP and DOP can be filed separately or at the same time, but neither is valid unless both are filed with the Department
of Health, Center for Health Statistics.
If you choose to send the forms together, only one non-refundable filing fee of $18 is
required. Otherwise, two non-refundable $18 filing fees are required.
Definitions
− “Alleged genetic parent” means an individual who is alleged to be, or alleges that the individual is, a genetic parent or
possible genetic parent of a child whose parentage has not been adjudicated. The term includes an alleged genetic
father and alleged genetic mother (RCW 26.26A.010(3)).
− “Assisted reproduction” means a method of causing pregnancy other than sexual intercourse (RCW 26.26A.010(4)).
− “Intended parents” means an individual, married or unmarried, who manifests an intent to be legally bound as a
parent of a child conceived by assisted reproduction (RCW 26.26A.010(13)).
− “Presumed parent” means an individual who is presumed to be a parent of a child, unless the presumption is
overcome in a judicial proceeding, a valid denial of parentage, or a court adjudicates the individual to be a parent
(RCW 26.26A.010(17)). A person is presumed to be the parent of the child if:
o The individual and birth parent were married to or in a state registered domestic partnership with each other
and the child was born during the marriage or partnership; or
o The individual and birth parent were married or in a state registered domestic partnership with each other and
the child is born within 300 days after the marriage is terminated by death, annulment, divorce, dissolution or
declaration of invalidity; or
o The individual and birth parent were married or entered into a state registered domestic partnership with each
other after the birth of the child and filed an assertion with the Department of Health; or
o The individual and birth parent were married or entered into a state registered domestic partnership with each
other after the birth of the child and agreed to be named as a parent of the child on the birth certificate; or
o The individual seeking to establish parentage resided in the same household with the child for the first four
years of life of the child, including any period of temporary absence, and openly held out the child as the
individual’s child (RCW 26.26A.115).
− “Witnessed” means at least one individual who is authorized to sign has signed a record to verify that the individual
personally observed a signatory sign the record (RCW 26.26A.010(23)). A third party person signing the witnessed
statement must be at least 18 years of age and not related by blood or marriage to the individuals who sign a
voluntary acknowledgment of parentage, denial of parentage, or rescission of parentage form.
− “Notarial officer” means a notary public or other individual authorized to perform a notarial act (RCW 42.42.010(9)).
If you need help understanding your rights and responsibilities as parents and the alternatives to, and
consequences of, signing this form, call the Division of Child Support at 1-800-442-5437.