Free Instructions - New Hampshire

Instructions for completing AFFIDAVIT OF MOTHER
(NHJB-2189-FP)

Form use. This form must be completed by the birth mother surrendering her parental rights. It is intended to identify the father of the child. Top part of form ·COURT NAME: Enter the name of the county probate court where the document will be filed. (example: Belknap County Probate Court; Rockingham County Probate Court). ·CASE NAME: Enter the birth name of the child (example: Adoption of John Adams; Adoption of Susan Jones). ·CASE NUMBER: Leave blank if not yet assigned by court OR fill in case number if it is known. Line below form title Enter your name on the first blank line. Enter your complete mailing address with zip code on the second blank line. Question 1 and 8 must be completed. Numbered part of form Please check off as many boxes that apply to your situation. For each check box you have marked, enter the additional information on the lines provided. 1. Enter the name of the child to be adopted, the child's date of birth, and the city and state where child was born on the appropriate lines provided. Enter the name of the child's father and his complete mailing address on the lines provided. Check off one box to indicate the marital status of birth mother ­ single, married, or divorced. If married or divorced is selected, enter the name of spouse and date of marriage and, if applicable, date of divorce on the lines provided. Check off this box ONLY if you do not want to name the child's father. Check off this box ONLY if you have not and are not living with any man who has provided support to you or your child, and who says he is the child's father. Check off this box ONLY if you have and are living with the man who has provided support to you or your child and who says he is the child's father. Enter his name and mailing address on the appropriate lines provided. Check off this box if, to the best of your knowledge, no person has claimed to be the father of your child named in this affidavit and no person has filed a claim with Child Support Services, Division of Health and Human Services. Check off this box to provide a list of the other names you have used since your birth. On the lines provided, enter the other names used.

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NHJB-2189-P Instructions (10/01/06)

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Signature section This form must be signed in the presence of a Notary Public or Justice of the Peace. They will complete the section immediately following your signature. You will sign the form on the Birth Mother's signature line, and date it in the appropriate space to the left.

Review the completed form for accuracy prior to filing it with the court. If completing this form on-line, some fields may be filled in automatically based on entries in other fields. If more space is needed for any question, please attach additional sheets of paper.

NHJB-2189-P Instructions (10/01/06)

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