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Affidavit of Birth Information Homebirths

This document is an affidavit certifying the birth details for a home birth, including the child's name, sex, date and time of birth. It requires signatures from the parent(s), witness of the birth, and attendant such as a midwife. It states that any false statements could result in criminal liability including perjury charges. The document must be notarized unless a midwife was involved in the delivery.

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Chaellin Villaraiz Deguit Barcenas
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224 views1 page

Affidavit of Birth Information Homebirths

This document is an affidavit certifying the birth details for a home birth, including the child's name, sex, date and time of birth. It requires signatures from the parent(s), witness of the birth, and attendant such as a midwife. It states that any false statements could result in criminal liability including perjury charges. The document must be notarized unless a midwife was involved in the delivery.

Uploaded by

Chaellin Villaraiz Deguit Barcenas
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Affidavit of Birth Information for Homebirths (Certifier’s Statement)

I swear or affirm that the information stated is true and correct to the best of my knowledge and belief. I certify that the
child named herein was born alive to the stated mother at the place, date, and time shown on this worksheet.

This worksheet was completed with the understanding that the facts so stated herein afford a full, complete, and truthful
representation of facts and what my testimony shall be should I be asked or directed to testify to the facts herein in a court
of law. I realize that any false statement of facts or information made herein could subject me to the risk of criminal liability,
including, but not limited to, persecution for perjury.
Child’s First Name Middle Last
Information
Sex Date of Birth Time of Birth

Parent Printed Name Written Signature


Verification 
Relationship to Child Date Signed Phone Number
Mother/Parent
Father/Parent
Witness Printed Name Written Signature
(certifier) 
Verification How long have you known How do you know the Mother?
Saw the Mother Pregnant the Mother?
Signature must Saw the Mother Deliver
be notarized Saw the Newborn baby Years Months
Address – Street Name and Number County
(Not required if
a midwife was City State Zip
involved in the
delivery) Relationship to Child Date Signed Phone Number

Attendant Printed Name Written Signature


Verification 
Address – Street Name and Number County
(Physician,
Certified Nurse City State Zip
Midwife, or
Licensed State License Number NPI Date Signed Phone Number
Midwife)
Registrar’s Printed Name Registrar’s Written Signature
FOR VITAL 
RECORDS USE Date Signed District and Local Number
ONLY
Denied Registered ____________________

NOTARY ACKNOWLEDGEMENT

State of _____________________

County of ___________________

Signed and sworn to (or affirmed)before me on this ______ day of __________, 20 _____, by __________________________________
Day Month Witness

(official Seal) ________________________________ ______________________________,Notary Public


Official Signature of Notary Notary’s printed or typed name

My Commission expires on:________________

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