STATE OF CONNECTICUT-DEPARTMENT OF PUBLIC HEALTH
VITAL RECORDS SECTION - PARENTAGE REGISTRY
ACKNOWLEDGMENT OF PARENTAGE
INTRODUCTION
Children need and benefit from the active involvement of both parents in their daily lives. One of the best ways to ensure this active
involvement is to establish the legal parentage of both parents. And one of the easiest ways to establish legal parentage of both parents is to
complete this form. Completion of this Acknowledgment of Parentage at the time of birth or at any time after birth is voluntary.
Persons responsible for the preparation and filing of birth records, such as hospital staff, are required to accept the Acknowledgment of
Parentage up to 10 days from discharge as a basis for including the acknowledging parent’s information on the birth certificate. If the parents
are not married to each other, completing the Acknowledgment of Parentage is a simple way to establish parentage and have the
acknowledging parent listed on the birth certificate.
If parentage is established later on, after a birth certificate has already been created, this form must be submitted to the Parentage Registry at
the Department of Public Health (please reference instructions at bottom of this page). Once parentage has been established through
completion of the Acknowledgment of Parentage, the birth certificate will be amended to include the acknowledging parent’s information and
any requested change to the child’s name as identified on the Acknowledgment of Parentage.
INSTRUCTIONS
Before completing the Acknowledgment of Parentage, please read these instructions and the NOTICE OF RIGHTS AND
RESPONSIBILITIES on the back of the Acknowledgment of Parentage.
ALL FIELDS ON THE FORM MUST BE COMPLETED.
IF THE INFORMATION ASKED FOR DOES NOT APPLY TO YOU, ENTER “N/A”.
1. If you have any questions, you should talk to an attorney. Information concerning state child support services can be obtained from any
local office of the Connecticut Department of Social Services (DSS), Office of Child Support Services. The address of the local DSS
office nearest you can be found in the blue pages of a local telephone book.
2. Print all information requested except for your signature. Use a black ball point pen and press hard enough to make the copies.
3. Fill in all spaces. List your health insurance company, even if it will not cover the hospital bill for the child’s birth. If you do not have
health insurance, put “none” in that space.
4. If you are completing the Acknowledgment of Parentage in a location other than the hospital where the child was born, remember to sign
it in front of an authorized official. You may do this in another state. Leave all pages together until both parents have signed.
5. Both parents must sign their legal names on this form in front of a notary public, or other authorized officer. Show the notary or other
officer a photo identification of yourself, such as your driver’s license, motor vehicle identification card, passport, etc. If you are
completing this form at the hospital or birthing center right after your child is born, tell the staff when you are ready to sign it. They will
assist you with obtaining the services of a notary public.
6. Next to your signature put the date you actually signed the form. It does not have to be the same date the other parent signed.
**********************************************
After this form has been completed, signed, and sworn to by both parents, each parent will receive and need to keep a copy of the form (see
copy distribution at bottom of form). The completed original (white) copy must be sent to the address listed below. If this form is being
completed at a hospital or a local DSS office, the hospital or DSS office will forward it to DPH. If you are completing the form on your own
or with the assistance of an attorney, you or the attorney must send the original (white) copy to the Department of Public Health
Connecticut Department of Public Health
Vital Records Section - Parentage Registry
410 Capitol Avenue- MS#11VRS
P. O. Box 340308
Hartford, CT 06134-0308
Telephone: (860) 509-7958
rev 01/22
SAMPLE
Acknowledgment of Parentage
NOTICE OF RIGHTS AND RESPONSIBILITIES
Read all sections before you sign the form.
By signing this form, the Birth Parent and Acknowledging Parent affirm the following:
1. We understand that the acknowledgment of parentage is equivalent to a legal finding of parentage that is binding on both parents,
whether adult or minor, and may only be challenged under limited circumstances.
2. The birth certificate of the named child does not identify any other parent except for the birth parent or the acknowledging parent.
3. There is no other parent of the named child other than the birth parent and the acknowledging parent. This means that there is no
other acknowledged or adjudicated parent, person who consented to assisted reproduction by the birth parent with the intent to
parent the conceived child along with the birth parent, or a person who signed a surrogacy agreement indicating such person’s intent
to parent the child conceived in accordance with such agreement.
4. There is no action pending in which the named child’s parentage is at issue, unless all parties to the action agree to the
establishment of the signatory’s parentage pursuant to the acknowledgment.
NOTICE OF RIGHTS AND RESPONSIBILITIES TO BIRTH PARENT AND ACKNOWLEDGING PARENT
1. You do not have to sign the Acknowledgment of Parentage and you should not sign the form if you are unsure about whether
the acknowledging parent meets the legal requirements of parentage, as specified in Public Act 21-15, or if you do not fully
understand the rights and responsibilities that you will have upon signing the Acknowledgement of Parentage.
2. For an acknowledging parent who is signing as the genetic father, genetic testing (DNA) may be able to establish parentage with
a high degree of accuracy, and may, under certain circumstances, be available at state expense. For the purposes of this form, a
genetic father is defined as the person whose sperm fertilized the egg that resulted in the conception of the named child, and in
which no surrogacy arrangement was used.
3. Once this form is completed, it will be filed with the Connecticut Department of Public Health, Parentage Registry, and the
acknowledging parent’s name will be placed on the birth certificate if not already listed.
4. As a legal parent, the person acknowledging parentage may obtain rights of custody and visitation, and also will be responsible
for the child’s financial support at least until the child’s eighteenth birthday.
5. Your child may be eligible for many other benefits from the acknowledged parent such as health insurance, social security,
veteran’s benefits, and the right of inheritance.
ACKNOWLEDGING PARENT’S RIGHTS AND RESPONSIBILITIES – In addition to the rights and responsibilities listed above, as the
acknowledging parent you will have the following rights and responsibilities.
1. You have the right to deny parentage and to have your case heard by a court or a family support magistrate.
2. You have the right to speak with an attorney before signing an Acknowledgment of Parentage. In addition, if there is a trial
concerning the parentage of a child, you have the right to have an attorney represent you and, if you are alleged to be the genetic
parent of the child and cannot afford an attorney, you can ask the court to appoint one for you.
3. As legal parent of the child, you will be liable for the child’s financial and medical support at least until the child’s eighteenth
birthday. If you do not support your child, a civil or criminal court case may be brought against you, and the court may order
that your income be withheld.
4. The child will be given many rights and benefits which the child may otherwise not have, such as the right to inherit from you,
as the legal parent, and be eligible to receive health insurance, social security, or veteran’s benefits.
RESCISSION
1. Either parent may rescind the Acknowledgment of Parentage within 60 days of signing the Acknowledgment of Parentage (or
within 60 days of the child’s birth date if signed prior to birth), by contacting the Connecticut Department of Public Health,
Vital Records Section-Parentage Registry or any field office of the Connecticut Department of Social Services (DSS), Office of
Child Support Services, and completing a Rescission of Acknowledgment of Parentage form (VS-57 form). The addresses of
DSS field offices can be found on the Connecticut DSS website. After signing the VS-57 form in front of a notary public or
other authorized official, forward the original to: Connecticut Department of Public Health, Vital Records Section-Parentage
Registry, 410 Capitol Avenue, First Floor, MS #11VRS, P.O. Box 340308, Hartford CT 06134-0308.
2. If either parent signs the Rescission of Acknowledgment of Parentage (VS-57 form), the acknowledging parent’s name will be
removed from the birth certificate and the person will no longer be considered the legal parent of the child, unless legal parentage
is established in an alternative way.
3. After 60 days from the signing of the Acknowledgment of Parentage (or after 60 days of the child’s birth date if signed prior to
birth), the acknowledging parent’s name will be removed from the birth certificate only by order of the court. An
Acknowledgment of Parentage may be challenged in the court or before a family support magistrate after the 60-day rescission
period only on the basis of fraud, duress, or material mistake of fact, with the burden of proof upon the person making the
challenge.
IF EITHER ONE OF YOU IS NOT ABSOLUTELY SURE THAT THE ACKNOWLEDGING PARENT MEETS THE LEGAL
REQUIREMENTS OF PARENTAGE, YOU SHOULD NOT SIGN THIS Acknowledgment of Parentage. If you have any
questions you should talk to an attorney.
SAMPLE
Form VS-56 (Rev. 11/21) Distribution: White-Vital Records/DPH Yellow – Originator Pink – Birth Parent Gold – Acknowledging Parent
CHILD
CHILD’S NAME (As it currently appears on birth certificate)(First)
(Middle)
(Last)
SEX MALE FEMALE
NON-BINARY
DATE OF BIRTH
IS THE CHILD’S NAME TO BE CHANGED?
NO YES *if yes, complete line item below
CHILD’S NAME (As it will appear on new birth certificate) (First)
(Middle)
(Last)
PLACE OF BIRTH (CITY) (STATE)
BIRTH PARENT
CURRENT NAME (First)
(Middle)
(Last)
(Last Name Prior to Marriage If applicable)
DATE OF BIRTH
TELEPHONE NUMBER
SOCIAL SECURITY NO.
RESIDENCE (No. and Street) (Town) (State or Foreign Country) (Zip Code)
ACKNOWLEDGING PARENT
CURRENT NAME (First)
(Middle)
(Last)
(Last Name Prior to Marriage If applicable)
DATE OF BIRTH
PLACE OF BIRTH (CITY and STATE OR FOREIGN COUNTRY)
SOCIAL SECURITY NO.
TELEPHONE NUMBER
RESIDENCE (No. and Street) (Town) (State or Foreign Country) (Zip Code)
RACE (all that apply) White Black Asian Indian Chinese Filipino Japanese Korean Vietnamese Native Hawaiian Guamanian/ Chamorro Samoan
American Indian or Alaskan Native (specify tribe) _____________ Other Races (specify) _____________________________
Other Pacific Islander (specify) __________________ Other Asian (specify) If yes, specify : _____________________
HISPANIC ORIGIN?
NO YES
Specify: Puerto Rican Cuban Mexican Other (Specify) ________
EDUCATION LEVEL: (highest level COMPLETED)
8
th
Grade or less College/No degree Master’s degree
9
th
-12
th
grade no diploma Associates Doctorate/professional
degree H.S. graduate or GED Bachelors
OCCUPATION
BUSINESS/INDUSTRY
SPOKEN LANGUAGE: (include all)
English Spanish American Sign Language Armenian Chinese (Cantonese) Chinese (Mandarin) French (including Cajun, Patois) French
Creole Gujarathi Khmer Korean Laotian Persian Polish Portuguese Russian Serbo-Croatian Vietnamese Other Spoken Language (specify)________________
EMPLOYER
EMPLOYER’S ADDRESS (include City and State)
DO YOU HAVE MEDICAL INSURANCE?
YES NO
MEDICAL INSURANCE COMPANY NAME
POLICY NUMBER
We affirm that the acknowledging parent is the genetic father of this child and that the child was not born subject to a surrogacy agreement; OR
We affirm that the acknowledging parent meets at least one of the legal requirements to voluntarily establish parentage. Check all that apply:
This child was conceived through assisted reproduction with the consent of both of us and with the intention that we both raise this child.
We were legally married at the time of this child’s birth (or if the marriage ended, this child was born not later than 300 days after the date the
marriage ended).
The acknowledging parent resided with the birth parent in the same household with the child and openly held out the child as the person’s own
child from the time the child was born or adopted and for a period of at least two years.
BIRTH PARENT’S AFFIRMATION
ACKNOWLEDGING PARENT
I freely and voluntarily consent to this Acknowledgment of Parentage. The person
identified above as ‘ACKNOWLEDGING PARENT’ is authorized to sign this
Acknowledgment of Parentage under Connecticut law and is the parent of this child. I
have read or have had read to me, and have had explained to me, the affirmations and
the rights and responsibilities on the back of this form, and I understand and agree to
the contents. I have had the opportunity to ask questions before I signed this form. A
copy of this statement has been given to me. I attest that the above information that I
have provided is true and correct to the best of my knowledge.
__________________________________________________________________________
Birth Parent Signature (use current last name) Date
I freely and voluntarily acknowledge that I am the parent of the child named above,
and I am authorized to sign this Acknowledgment of Parentage under Connecticut law.
I accept the obligation to support this child and I understand that an order for child
support may be entered. I waive my rights to a trial, a lawyer to represent me, and a
genetic test to determine parentage, if applicable. I have read or have had read to me,
and have had explained to me, the affirmation and rights and responsibilities on the
back of this form, and I understand and agree to the contents. I have had the
opportunity to ask questions before I signed this form. A copy of this statement has
been given to me. I attest that the above information that I have provided is true and
correct to the best of my knowledge.
________________________________________________________________________
Acknowledging Parent’s Signature (use current legal name) Date
____________________ ________________ _____________________________
State of County of Town of
Sworn and subscribed
before me on this _________Day of ______________________, 20_________
Signature of Witness or
authorized officer: ____________________________________________________
Name and title of Witness
authorized officer: __________________________________ _________________
(title)
If notary, date commission expires:______________________________
____________________ ________________ _________________________
State of County of Town of
Sworn and subscribed
before me on this _________Day of ____________________, 20_________
Signature of Witness or
authorized officer: _________________________________________________
Name and Title of Witness
authorized officer: _________________________ ______________
(title)
If notary, date commission expires:________________________
PLACE COMPLETED
Hospital DPH Other DSS Regional Office
PLACE COMPLETED
Hospital DPH Other DSS Regional office
CONNECTICUT DEPARTMENT OF PUBLIC HEALTH
OFFICE OF VITAL RECORDS PARENTAGE REGISTRY
ACKNOWLEDGMENT OF PARENTAGE
Check One: At Birth Post Birth
This is a legal document. Complete in
BLACK ball point pen and do not alter.
SAMPLE