Nebraska Revised Statutes Chapter 43. Infants and Juveniles § 43-104.09. Child born out of wedlock; biological mother; affidavit; form

In all cases of adoption of a minor child born out of wedlock, the biological mother, or an individual acting on behalf of the biological mother and who possesses information provided by the biological mother if the biological mother is unavailable due to death, incapacity, abandonment, or termination of parental rights, shall complete and sign an affidavit in writing and under oath. The affidavit shall be completed and signed before or at the time of execution of the consent or relinquishment and shall be filed with the court prior to the hearing on the petition for adoption. If the biological mother is under the age of nineteen, the biological mother may sign the affidavit despite her minority or the affidavit may be completed and signed by the agency or attorney representing the biological mother based upon information provided by the biological mother. The affidavit shall be in substantially the following form:

AFFIDAVIT OF IDENTIFICATION

I, __________, the mother of a child, state under oath or affirm as follows:

The name of the biological father is __________.

His last-known home address is __________.

His last-known work address is __________.

He is __________ years of age, or he is deceased, having died on or about the __________ day of __________, __________, at __________, in the State of __________.

He has been adjudicated to be the biological father by the __________ Court of __________ county, State of __________, case name __________, docket number __________.

He ___ has ___ has not acknowledged paternity in court or in connection with the child's birth certificate.

He ___ has ___ has not established a familial relationship with the child.

(For other possible biological fathers, please use additional sheets of paper as needed.)

_____ Conception of my child occurred as a result of sexual assault or incest

_____ Providing notice to the biological father of my child would threaten my safety or the safety of my child

_____ Other reason: _______________.

______________________________

______________________________

______________________________

(use additional sheets of paper as needed).

I am signing it as my free and voluntary act and understand the contents and the effect of signing it.

Dated this _____ day of _____, _____.

(Acknowledgment)

_____________

(Signature)