Required and Optional Data Elements for VAP 02092021

OMB# 0970 – 0171

Expiration Date: XX/XX/2027

Table 1: Complete List of Required and Optional Data Elements

REQUIRED DATA ELEMENTS	OPTIONAL DATA ELEMENTS
1. Current Full Name (mother, father and child)	1. Daytime Phone Number (mother and father)
2. Social Security Number (mother and father)	2. Birthplace - mother and father (city, county & state)
3. Date of Birth (mother, father and child)	3. Hospital of Birth (child)
4. Address (mother and father)	4. Gender of Child
5. Birthplace - child (city, county & state)	5. Father's Employer
6. Legal Finding (60 day rescission)	6. Ethnicity of Father
7. Rights and Responsibilities, Alternatives and Consequences	7. Medical Insurance
8. Signature Lines for Parents	8. Maiden Name of Mother
9. Notary Seals/Witnesses: Signature Lines	9. Place Where Acknowledgment or Affidavit Was Completed
	10. Offer of Name Change (child)
	11. Minors: Signature Line for Guardian Ad Litem or Legal Guardian
	12. Three-Way Signature Offered on Form (husband, wife, and biological father)
	13. An advisory to parents that they may wish to seek legal counsel or obtain a genetic test before signing
	14. A statement concerning the custody status of the child vis-a-vis State law

The Paperwork Reduction Act of 1995 (Pub. L. 104-13): STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to provide the required and optional data elements for the state-developed affidavit used by hospitals, birth record agencies, and other partners participating in a state's voluntary paternity establishment program.  Public reporting burden for this collection of information is estimated to average .17 hours per process, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This collection of information is required for specifying the minimum requirements for voluntary acknowledgment of paternity (section 452(a)(7) of the Social Security Act).  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0171 and the expiration date is XX/XX/2027. If you have any comments on this collection of information, please contact OCSS by email at OCSS.DPT@acf.hhs.gov