Form Cs-127 - Acknowledgment Of Paternity (Reconocimiento De Paternidad) Page 4
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8ARIZONA DEPARTMENT OF ECONOMIC SECURITY
CS-127 (11-17) Page 4
Office of Vital Records
ADDITIONAL INFORMATION REGARDING THE FATHER LISTED ON
THE ACKNOWLEDGMENT OF PATERNITY
(for birth certificate processing purposes)
The Arizona Department of Health Services’ Office of Vital Records is required to collect and report data to the Department of Health
and Human Services’ National Center for Health Statistics (NCHS). Please complete the data below in order to capture this information
for statistical purposes. Thank you in advance for completing this information.
CHILD’S NAME (First, Middle, Last, Suffix)
BIRTHDATE
MOTHER’S NAME (Last, First, M.I.)
FATHER’S NAME (Last, First, M.I.)
FATHER’S EDUCATION (Check One)
What is the highest level of schooling you will have completed at the time of the child’s delivery? Check one of the following boxes that
best describes your education. If you are currently enrolled, check the box that indicates the previous grade or highest degree received.
8th grade or less
Associate degree (e.g. AA, AS )
9th – 12th grade, no diploma
Bachelor’s degree (e.g. BA, AB, BS )
High school graduate or GED completed
Master’s degree (e.g. MA, MS MEng, Med, MSW, MBA )
Some college credit, but no degree
Doctorate degree (e.g. PhD, EdD) or
Professional degree (e.g. MD, DDS, DVM, LLB, JD )
FATHER’S RACE (Check All That Apply)
White
Other Asian
Black, African American
Specify:
American Indian or Alaska Native (*see list below)
Specify:
Primary or Enrolled tribe:
Native Hawaiian
Additional Tribe:
Guamanian or Chamorro
Samoan
Additional Tribe:
Other Pacific Islander
Additional Tribe:
Specify:
Asian Indian
Chinese
Specify:
Filipino
Other
Japanese
Specify:
Korean
Specify:
Unknown
Refused
Not Obtainable
*Please select the appropriate Arizona tribe(s) the father is affiliated with from the list provided below and print the tribe name in the
space(s) provided above. If the father is affiliated with a non-Arizona tribe, please write “other” in the space provided or print the name
of the non-Arizona tribe.
Ak Chin Indian Community
Navajo Tribe
Camp Verde Yavapai Apache
Pascua Yaqui
Cocopah Tribe
Prescott Yavapai Indian Community Quechan Tribe
Colorado River Indian Tribes
Salt River Indian Community (Pima)
Fort Mohave Tribe
San Carlos Apache Tribe
Ft. McDowell Mohave-Apache Community Gila River Indian Community
San Juan Southern Paiute Band
(Pima) Havasupai Tribe
Tohono O’Odham Tribe (Papago)
Hopi Tribe
Tonto Apache
Hualapai Tribe
White Mountain Apache Tribe (Fort Apache)
Kaibab Band of Paiute Indian
FATHER’S HISPANIC ORIGIN (Check One)
Dominican, Columbian)
No, not Spanish, Hispanic or Latino
Yes, Mexican, Mexican American, Chicano
Specify:
Yes, Puerto Rican
Specify:
Yes, Cuban
Unknown
Refused
Not Obtainable
Yes, other Spanish/Hispanic/Latina (e.g. Spaniard, Salvadoran,
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