Form Cs-127 - Acknowledgment Of Paternity (Reconocimiento De Paternidad) Page 3

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CS-127 (11-17) Page 3
NOTICE OF ALTERNATIVES, THE LEGAL CONSEQUENCES
AND RIGHTS AND RESPONSIBILITIES
PLEASE READ THIS INFORMATION CAREFULLY BEFORE YOU SIGN THE FORM
The purpose of this form is to acknowledge paternity for a child born out of wedlock.
We, the natural mother and natural father, declare that the information provided is true and correct. We acknowledge that
the father named is the only possible father of the child named.
If the mother was married at any time in the ten months immediately preceding the birth or the child is born within ten
months after the marriage is terminated by death, annulment, declaration of invalidity or dissolution of marriage or after
the court enters a decree of legal separation, a Waiver of Paternity Affidavit must accompany this document pursuant to
A.R.S. § 25-814.
I understand that if the current/former husband’s location is unknown to the mother, the mother will be required to apply for
IV-D Services and The Division of Child Support Services will attempt to locate the current/former husband.
I understand that by signing this acknowledgment we are giving up our right to a court hearing to determine paternity as
well as the right to have genetic testing done to determine the parentage of this child.
I further understand we may have a right to rescind or challenge this acknowledgment as outlined in A.R.S. § 25-812.
I understand the signing of this acknowledgment will result in the legal determination of paternity.
I understand that upon the determination of paternity, both parents have a legal obligation to support their child pursuant
to A.R.S. § 25-501 as well as other duties imposed by Arizona law.
I understand this paternity determination is not a custody order but provides a basis for determining issues related to cus-
tody and visitation and affords the parents all rights and responsibilities provided by Arizona law.
I understand that either parent has a right to cancel the Acknowledgment of Paternity by completing an Affidavit of Paterni-
ty Rescission within 60 days from the date of the last witnessed/notarized signature on the Acknowledgment and sending
it to the Hospital Paternity Program pursuant to A.R.S. § 25-812. I have read the information provided and received oral
notification of our rights and responsibilities by either speaking to staff, viewing a paternity video or phoning 1-800-485-
6908.
A voluntary Acknowledgment of Paternity filed with The Department of Economic Security or The Department of
Health Services has the same force and effect as a Superior Court judgment pursuant to A.R.S. § 25-812.
I further declare this statement to be made for recording with the Clerk of the Superior Court, the Department of Economic
Security or the Department of Health Services pursuant to A.R.S. § 25-812 and hereby consent and request that the birth
certificate be amended to show the father’s name and to show the child’s name as requested on the front of the Acknowl-
edgment of Paternity. Please note: Any questions regarding name changes should be directed to the Arizona Department
of Health Services, Office of Vital Records at (602) 364-1300.
I understand that if it is deemed appropriate by DES, this acknowledgment may be used to obtain a paternity order in any
Arizona county having venue.
I understand that I am required to provide my Social Security Number pursuant to 42 USC § 652(a)(7) and 666(a)(5)(IV).
DES/DCSS will use this information to establish paternity and if appropriate, to establish and enforce a child support order.
I swear or affirm under penalty of perjury pursuant to A.R.S. § 13-2702 that this application and/or accompanying docu-
ments have been examined by me and to the best of my knowledge and belief are true and correct.
WHAT DOES IT MEAN IF YOU SIGN THIS FORM?
By signing this Acknowledgment of Paternity you are legally establishing your child’s paternity. Paternity means legal
fatherhood.
Signing this form is voluntary. You should not sign this form if you have been threatened or coerced.
This Acknowledgment does not automatically give the father visitation or custody rights, but he may use it to ask the Court
for them.
Either parent can rescind this form within 60 days of the last signature on the form by signing an Affidavit of Paternity Re-
scission (CS-258). To request an Affidavit of Paternity Rescission, contact the Hospital Paternity Program at
1-800-485-6908.

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