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-D
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 I do not know the identity of said child's biological father is because at or about the time the said child was conceived (Reason)
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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.
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Mother's Signature
SWORN TO AND SUBSCRIBED before me on this, the _____________ day of _________________, A.D., 20 ______.
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Notary Public
My Commission Expires:
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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-D