ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Division of Child Support Services
GO TO FORM
ACKNOWLEDGMENT OF PATERNITY
READ ALL INSTRUCTIONS CAREFULLY AND REMOVE THIS PAGE BEFORE COMPLETION
The purpose of this form is to acknowledge paternity for a child born out of wedlock.
This Acknowledgment of Paternity IS NOT applicable if the mother of the child was married at the time of birth or was
married at any time in the ten months immediately preceding such birth pursuant to A.R.S. § 25-814, unless accompanied
by a Waiver of Paternity Affidavit.
Read the “Acknowledgment of Paternity” (CS-127) and the Notice of Alternatives, The legal Consequences and the
Rights and Responsibilities.
Only use BLACK INK. Colored inks ARE NOT ACCEPTABLE. Type or print all required information except where sig-
natures are required. The Spanish translation on the last page is for reference only. Please complete the English side.
DO NOT MAKE CORRECTIONS ON THE FORM. Forms with crossouts, erasures, alterations, etc., will invalidate
the Acknowledgment. DO NOT SUBMIT AN ACKNOWLEDGMENT CONTAINING SUCH CHANGES. If you make a
mistake, ask for a new form and begin again.
Fill in every blank or box on the form. Incomplete or incorrect information may cause delays in the filing of the
In cases of multiple births, a separate Acknowledgment for each child must be completed.
The Acknowledgment must be signed in the presence of a Witness or Notary Public. Each parent must sign
their name on all copies of the form and each signature must be witnessed or notarized. Each parent must show the
Witness or Notary appropriate, valid identification. The parents should use their legal name only. Nicknames, short-
ened name, etc., SHOULD NOT be used. Your Legal Name is the one that appears on your birth certificate, or other
If both parents cannot sign the Acknowledgment at the same time, use a separate Acknowledgment. When signing
separate Acknowledgments the child’s information should be identical on each form. All blanks must be completed
and both Acknowledgments submitted together.
If you are changing the child’s name, after 3 months of age only the last name of the child can be changed using
this form. Any other changes must be requested through the Office of Vital Records.
If completing this Acknowledgment away from the hospital, remember to sign in the presence of a Notary Public
or qualified Witness. A qualified Witness must be at least 18 years old and not related to either parent by blood or
marriage. Notary Publics are listed in the telephone directory. RETURN ALL PAGES (excluding completion instruc-
tions) OF THE ACKNOWLEDGMENT. Mail the entire document to:
DCSS Hospital Paternity Program – HPP
PO BOX 64533
Phoenix, AZ 85082
If you require a copy of the birth certificate, mail your application monies, along with the birth certificate application, to
the address listed on the birth certificate application. DO NOT mail any monies to the Hospital Paternity Program.
DES - Department of Economic Security
DHS - Department of Health Services
DCSS - Division of Child Support Services
HOW WILL YOUR CHILD BENEFIT IF YOU SIGN THIS FORM?
Every child has the right to know his or her mother and father and benefit from a relationship with both parents.
Your child will have two legal parents.
Your child has a right to financial support from both parents.
It will be easier for your child to learn the medical histories of both parents and to benefit from health care coverage
available to you.
It will be easier for your child to inherit through you and receive benefits such as dependent or survivor’s benefits from
Veterans Affairs or the Social Security Administration
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the
Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of
1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination
in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, dis-
ability, genetics and retaliation. To request this document in alternative format or for further information about this policy,
contact 602-252-4045; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request.
Ayuda gratuita con traducciones relacionadas con los servicios del DES esta disponible a solicitud del cliente.