Form Cs-258 - Affidavit Of Paternity Rescission

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Completion Instructions for CS-258
AFFIDAVIT OF PATERNITY RESCISSION
READ ALL INSTRUCTIONS CAREFULLY
A.
Purpose. To rescind paternity established under A.R.S. § 36-334.
The Affidavit of Paternity Rescission may only be used by parents who established paternity by filing an Acknowledgment of
Paternity (CS-127) with the Arizona Department of Health Services, Office of Vital Records or the Clerk of Court.
Either parent may rescind the Acknowledgment of Paternity within the earliest of: Sixty days from the last signature affixed
to the acknowledgment or the date of a proceeding relating to the child in which the mother or father is a party. After sixty
days relief may only be sought under A.R.S. § 25-812.
A copy of the Affidavit of Paternity Rescission will be forwarded to the Arizona Department of Health Services, Office of
Vital Records for the purpose of amending the child’s birth certificate if the child was born in Arizona. The father’s name
will be removed and he will no longer be the child’s legal father.
B.
Completion.
Only use BLACK INK. Colored inks ARE NOT ACCEPTABLE. Type or print all required information except where
signatures are required.
DO NOT MAKE CORRECTIONS ON THIS FORM. Forms with cross outs, erasures, alterations, etc., will invalidate the
Affidavit. DO NOT SUBMIT AN AFFIDAVIT 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 Affidavit.
The Affidavit of Paternity Rescission must be signed in the presence of a Notary Public. The Notary Public will require
photo identification from the party signing the form.
Only one child may be named on the Paternity Rescission. In cases involving multiple children the parent seeking the
rescission should complete a separate Paternity Rescission for each child.
Return all pages of the completed Affidavit of Paternity Rescission to:
DES/DCSS
Hospital Paternity Program
P.O. Box 40458
Phoenix, AZ 85067
Any questions about the Affidavit of Paternity Rescission should be directed to:
Division of Child Support Services
Customer Service Unit, (602) 252-4045
or
Hospital Paternity Program, 1-800-485-6908
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, disability,
genetics and retaliation. The Department must make a reasonable accommodation to allow a person with a disability to take part in
a program, service or activity. For example, this means if necessary, the Department must provide sign language interpreters for
people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take any
other reasonable action that allows you to take part in and understand a program or activity, including making reasonable changes
to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability,
please let us know of your disability needs in advance if at all possible. To request this document in alternative format or for further
information about this policy, contact the Division of Child Support Services at (602) 252-4045; TTY/TDD Services: 7-1-1. • Free
language assistance for DES services is available upon request. • Español en el reverso.

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