New York Acknowledgment of Parentage (LDSS-5171)

Who can use this form

• An unmarried birth parent and the alleged genetic parent.
• A married or unmarried birth parent and an intended parent of a child conceived through assisted reproduction.
• Do not sign if the birth parent of a naturally conceived child was married during the pregnancy or at the birth, if more than one person could be the other parent, or if you have any doubts about parentage.
• Do not sign if a court has already determined parentage, a valid acknowledgment was already signed, the child is the subject of a surrogacy agreement, the child has not been born, or the birth certificate already has two parents.
• Each parent's signature needs two witnesses who are not related to either parent.

What to send with it

• The original form, typed or printed clearly in black ink and signed by both parents and their witnesses.
• If signed at a hospital or social services district, the original is filed for you with the registrar.
• If signed anywhere else, mail or take the original to the registrar of the district where the birth certificate is filed.
• For births in New York City, the form says to mail or take it to the New York City Department of Health and Mental Hygiene, Office of Vital Records, Corrections Unit.
• The mailing address of each parent, and of a gamete donor if known, printed on the last page.

Where to send it

Mail to

See the form for where to file it.

State fee

The form prints no filing fee. For a child born in a hospital outside New York City, when the form is signed after the birth certificate was filed, the New York State Department of Health issues one free amended birth certificate to the birth parent; additional copies have a fee.

Typical processing

Not provided

Issued by

New York State Office of Temporary and Disability Assistance and New York State Department of Health

Form revision

Rev. 04/21

Source

Official government page