as of ________________ (month & day), _____(year), by _____________
(mother's name), of ________________________________________ (address),
complainant, and _______________________________________________ (Father's
name), of ________________________________________________________ (Address),
parties state that:
1. Complainant, bore a __________ (Gender)
child on ___________________ (month & day), __________ (year), at
___________________________________ (hospital address),
2. Defendant refutes that he is the father of
the child, but wants to prepare an agreement
which he can be released from all claims having to do with the child.
3. Complainant has heretofore filed claims
against defendant in the __________________ Court of ___________, County of
____________, State of __________ claiming that Defendant is the father of her
child and wanting support and maintenance of the child.
now releases defendant from all liability having to do with support or
maintenance of the child. Defendant and
Complainant shall prepare an agreement in which the Defendant shall reimburse
Complainant for childbirth expenses.
of Complainant) (Date)
of Defendant) (Date)