The department of job and family services shall prepare an acknowledgment of paternity affidavit that includes in boldface type at the top of the affidavit the rights and responsibilities of and the due process safeguards afforded to a person who acknowledges that he is the natural father of a child, including that if an alleged father acknowledges a parent and child relationship he assumes the parental duty of support, that both signators waive any right to bring an action pursuant to sections 3111.01 to 3111.18 of the Revised Code or make a request pursuant to section 3111.38 of the Revised Code, other than for purposes of rescinding the acknowledgment pursuant to section 3111.27 of the Revised Code in order to ensure expediency in resolving the question of the existence of a parent and child relationship, that either parent may rescind the acknowledgment pursuant to section 3111.27 of the Revised Code, that an action may be brought pursuant to section 3111.28 of the Revised Code, or a motion may be filed pursuant to section 3119.961 of the Revised Code, to rescind the acknowledgment, and that the natural father has the right to petition a court pursuant to section 3109.12 of the Revised Code for an order granting him reasonable parenting time with respect to the child and to petition the court for custody of the child pursuant to section 2151.23 of the Revised Code. The affidavit shall include all of the following:

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(A) Basic instructions for completing the form, including instructions that both the natural father and the mother of the child are required to sign the statement, that they may sign the statement without being in each other’s presence, and that the signatures must be notarized or witnessed;

(B) Blank spaces to enter the full name, social security number, date of birth and address of each parent;

(C) Blank spaces to enter the full name, date of birth, and the residence of the child;

(D) A blank space to enter the name of the hospital or department of health code number assigned to the hospital, for use in situations in which the hospital fills out the form pursuant to section 3727.17 of the Revised Code;

(E) An affirmation by the mother that the information she supplied is true to the best of her knowledge and belief and that she is the natural mother of the child named on the form and assumes the parental duty of support of the child;

(F) An affirmation by the father that the information he supplied is true to the best of his knowledge and belief, that he has received information regarding his legal rights and responsibilities, that he consents to the jurisdiction of the courts of this state, and that he is the natural father of the child named on the form and assumes the parental duty of support of the child;

(G) Signature lines for the mother of the child and the natural father;

(H) Signature lines for the notary public or witnesses;

(I) An instruction to include or attach any other evidence necessary to complete the new birth record that is required by the department by rule.