Form Cs-127 - Acknowledgment Of Paternity (Reconocimiento De Paternidad) Page 2
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8ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Clear the Form
CS-127 (11-17) Page 2
NO.
ACKNOWLEDGMENT OF PATERNITY
Formulario en Español
PLEASE PRINT CLEARLY. Complete in BLACK INK. DO NOT ALTER, LEGAL DOCUMENT
CHILD’S INFORMATION
CHILD’S NAME (First, Middle, Last, Suffix) AS IT APPEARS ON THE BIRTH CERTIFICATE
BIRTHDATE (MM/DD/YY)
MALE
FEMALE
PLACE OF BIRTH CITY
COUNTY
STATE
HOSPITAL
HOW YOU WANT THE CHILD’S NAME TO APPEAR ON THE BIRTH CERTIFICATE
IF THE CHILD’S NAME HAS NOT CHANGED, PLEASE PRINT THE CHILD’S NAME AS IT APPEARS ON THE ORIGINAL BIRTH CERTIFICATE
FIRST
MIDDLE
LAST
SUFFIX (Jr., II)
MOTHER’S INFORMATION
FIRST NAME
MIDDLE NAME
LAST NAME
MAIDEN NAME
BIRTHDATE (MM/DD/YYYY)
SOC. SEC. NO.
AREA CODE AND PHONE NO.
PLACE OF BIRTH (City, State)
COUNTRY OF BIRTH
ADDRESS: (Street, Apt. No., City, State, ZIP)
EMPLOYER
OCCUPATION
FATHER’S INFORMATION
FIRST NAME
MIDDLE NAME
LAST NAME
BIRTHDATE (MM/DD/YYYY)
SOC. SEC. NO.
AREA CODE AND PHONE NO.
PLACE OF BIRTH (City, State)
COUNTRY OF BIRTH
ADDRESS: (Street, Apt. No., City, State, ZIP)
EMPLOYER
OCCUPATION
The mother was legally married at the time of conception and/or birth of the child.
A Waiver of Paternity Affidavit completed by
A court order or decree of dissolution which rebuts paternity is attached.
the present/former husband is attached.
This Acknowledgment is being signed voluntarily with no threat or harm or duress. I have received written and oral notice and
have read the NOTICE OF ALTERNATIVES, THE LEGAL CONSEQUENCES AND RIGHTS AND RESPONSIBILITIES. I understand
my alternatives, the legal consequences and the rights and responsibilities. I swear and affirm under penalty of perjury
pursuant to A.R.S. §13-2702 that this application and any accompanying documents have been examined by me and to the
best of my knowledge and belief are true and correct.
SIGNATURE OF MOTHER (Sign only in presence of Witness) DATE
SIGNATURE OF FATHER (Sign only in presence of Witness)
DATE (MM/DD/YY)
MM/DD/YY
(
SIGNATURE OF WITNESS (TO BE COMPLETED BY THE [Check one]:
SIGNATURE OF WITNESS (TO BE COMPLETED BY THE [Check one]:
HOSPITAL
GOVERNMENT AGENCY
OTHER)
HOSPITAL
GOVERNMENT AGENCY
OTHER)
WITNESS MUST BE AT LEAST 18 YEARS OF AGE AND NOT RELATED BY BLOOD OR MARRIAGE.
PRINTED NAME OF WITNESS
PRINTED NAME OF WITNESS
ADDRESS
ADDRESS
ADDRESS
ADDRESS
------------------------------------------------------------------- NOTARY SECTION ------------------------------------------------------------------
TO BE COMPLETED BY A NOTARY PUBLIC ONLY IF NOT WITNESSED ABOVE
State of Arizona, County of
State of Arizona, County of
Subscribed and sworn or affirmed before me
Subscribed and sworn or affirmed before me
this
day of
,
this
day of
,
NOTARY PUBLIC
NOTARY PUBLIC
PLACE NOTARY SEAL HERE
PLACE NOTARY SEAL HERE
My Commission expires
My Commission expires
Check this box if form completed at the hospital.
Paternity Date
ALL COPIES OF THIS DOCUMENT MUST HAVE ORIGINAL SIGNATURES
For Office Use Only
*B*
THIS ACKNOWLEDGMENT IS BEING SIGNED VOLUNTARILY WITH NO THREAT OR HARM OR DURESS
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