Miss. Code. tit. 18, pt. 6, ch. 1, 18-6-1-G, ADOPTION ASSISTANCE, 18-6-1-G-XII, app 18-6-1-G-XII-C
STATE OF ___________________
COUNTY OF _________________
THIS DAY personally came and appeared before me, the undersigned Notary Public, in and for the aforesaid jurisdiction the within named ____________________________________ (Mother's full name) who, first having been by me duly sworn, on oath states the following;
That I, _________________________ (Mother's full name), am the biological mother of _______________________________ (Full name of child as on birth certificate), a female/male child born on the ________ day of _______________________, A.D., 20 ________, and that _______________________________ (Name of putative father) is the biological father of said child, whose last address known to me was _________________________ (Street)
_________________________ (City/ State/ Zip)
That ____________________________ (Name of putative father) and I are not now nor have we ever been married.
After having been fully advised that the making of false statement of identity under oath is punishable as perjury, I, the undersigned affiant, state that the matters and fact as herein set forth are true and correct, and I do hereby make this affidavit of my own free will and accord.
_____________________________
Mother's Signature
SWORN TO AND SUBSCRIBED before me on this, the _____________ day of ________________, A.D., 20 ______.
______________________________
Notary Public
My Commission Expires:
____________________
Miss. Code. tit. 18, pt. 6, ch. 1, 18-6-1-G, ADOPTION ASSISTANCE, 18-6-1-G-XII, app 18-6-1-G-XII-C