Table of Contents
The Arizona Acknowledgment of Paternity form, known as CS-127, plays a crucial role for parents who wish to establish paternity for a child born out of wedlock. This form is specifically designed for situations where the mother was not married at the time of the child's birth or during the ten months prior. If the mother was married, additional documentation, such as a Waiver of Paternity Affidavit, is necessary to proceed. Completing the form requires careful attention to detail; it must be filled out in black ink without any corrections or alterations. Each parent must provide accurate information, including their legal names as they appear on official documents, and the form must be signed in the presence of a witness or notary public. This ensures that both parents are voluntarily acknowledging their roles and responsibilities. The completed form not only establishes legal fatherhood but also opens the door for the child to receive financial support and benefits from both parents. Moreover, it allows for easier access to medical histories and inheritance rights. If there are multiple children, separate forms are required for each child, and any name changes after three months of age are limited to the child's last name. Understanding the implications of signing this form is essential, as it involves giving up certain rights, such as the right to a court hearing to determine paternity. However, both parents have the option to rescind their acknowledgment within 60 days if they choose to do so. Ultimately, the Acknowledgment of Paternity form serves as a vital legal document that facilitates the establishment of a child's family structure and rights in Arizona.
Guide to Writing Arizona Paternity
After filling out the Arizona Paternity form, you will need to ensure that all required signatures are obtained in the presence of a witness or notary public. Once completed, submit the form to the appropriate address to establish paternity legally.
- Read the entire “Acknowledgment of Paternity” form and the accompanying instructions carefully.
- Use only black ink to fill out the form. Do not use colored ink.
- Type or print all required information clearly, except where signatures are needed.
- Do not make any corrections on the form. If you make a mistake, request a new form.
- Fill in every blank or box on the form completely. Incomplete forms may cause delays.
- If there are multiple births, complete a separate acknowledgment for each child.
- Sign the acknowledgment in the presence of a witness or notary public. Each parent must sign all copies.
- Provide valid identification to the witness or notary public when signing.
- If both parents cannot sign at the same time, use separate forms, ensuring identical child information on each.
- If changing the child’s name, only the last name can be changed after three months of age using this form.
- Complete the form away from the hospital if necessary, ensuring signatures are witnessed or notarized.
- Return all pages of the acknowledgment (excluding instructions) to the designated address.
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Common Questions
What is the purpose of the Arizona Paternity form?
The Arizona Paternity form, known as the Acknowledgment of Paternity (CS-127), is designed to legally establish the paternity of a child born out of wedlock. This form is crucial for ensuring that both parents are recognized legally, which allows the child to benefit from financial support, medical history access, and inheritance rights from both parents.
Who should complete this form?
This form should be completed by both the mother and father of the child if they are not married. It is important to note that if the mother was married at the time of birth or within ten months prior, a Waiver of Paternity Affidavit must accompany the form. The acknowledgment is not applicable in such cases without this additional document.
What are the steps to properly fill out the form?
To fill out the form correctly, first read all instructions thoroughly. Use only black ink and ensure that all required fields are completed without any corrections or alterations. Each parent must sign the form in the presence of a witness or a notary public, and valid identification must be shown. If both parents cannot sign simultaneously, separate forms must be used, but the child’s information must match on both.
What happens if I make a mistake on the form?
If you make a mistake while filling out the form, do not attempt to correct it. Making corrections such as crossouts or erasures will invalidate the acknowledgment. Instead, request a new form and start over to ensure all information is accurate and complete.
Can I change my child's name using this form?
This form allows for a change of the child's last name only if the child is over three months old. Any other name changes must be requested through the Office of Vital Records. It's essential to follow the correct procedures for any name changes to avoid complications.
What are the legal consequences of signing this form?
By signing the Acknowledgment of Paternity, both parents are legally establishing paternity, which means they are recognized as the child's legal parents. This acknowledgment gives both parents rights and responsibilities, including the obligation to provide financial support. It does not automatically grant custody or visitation rights, but it can be used to request those rights in court.
How can I rescind the acknowledgment after signing?
If either parent wishes to rescind the acknowledgment, they can do so within 60 days of the last signature by completing an Affidavit of Paternity Rescission. This form must be sent to the Hospital Paternity Program. It's important to act quickly if there are any concerns about the acknowledgment.
Where should I send the completed form?
After completing the Acknowledgment of Paternity, send the entire document (excluding the instruction pages) to the following address: DCSS Hospital Paternity Program – HPP, PO BOX 64533, Phoenix, AZ 85082. Ensure that all pages are included for processing.
Dos and Don'ts
When filling out the Arizona Paternity form, it is crucial to follow specific guidelines to ensure the process goes smoothly. Here are six important dos and don'ts:
- Do read all instructions carefully before starting the form.
- Do use only black ink when filling out the form.
- Do fill in every blank or box to avoid delays.
- Do sign the form in the presence of a witness or notary public.
- Don't make any corrections or alterations on the form.
- Don't submit the form if it contains incomplete information.
Following these guidelines will help ensure that your Acknowledgment of Paternity is valid and processed without unnecessary complications.
Similar forms
The Arizona Acknowledgment of Paternity form is similar to a Birth Certificate Application. Both documents are essential for establishing legal parentage and ensuring the child’s identity is recognized officially. The Birth Certificate Application requires parents to provide their names and the child’s details, similar to how the Acknowledgment of Paternity establishes paternity. Both forms must be completed accurately and submitted to the appropriate state department to maintain the child’s legal rights.
Another document akin to the Arizona Paternity form is the Child Support Agreement. This agreement outlines the financial responsibilities of both parents towards their child. Like the Acknowledgment of Paternity, it is a legal document that requires signatures from both parents. It serves to protect the child’s financial interests, ensuring that both parents contribute to their upbringing, just as the paternity acknowledgment ensures legal recognition of both parents.
The Affidavit of Paternity Rescission is also similar. This document allows either parent to cancel the Acknowledgment of Paternity within a specified time frame. Just as the Acknowledgment establishes paternity, the rescission provides a legal pathway to dispute or withdraw that acknowledgment. Both documents require careful attention to detail and adherence to legal procedures to ensure they are valid.
The Waiver of Paternity Affidavit is another related document. If a mother was married at the time of her child’s birth, this affidavit allows her husband to waive his paternity rights. This is similar to the Acknowledgment of Paternity, which establishes the legal father’s rights and responsibilities. Both documents must be completed with precision and often require notarization or witnessing to be legally binding.
The Parenting Plan is comparable as well. It outlines the custody and visitation arrangements for the child. While the Acknowledgment of Paternity establishes who the legal parents are, the Parenting Plan details how they will share responsibilities and time with their child. Both documents aim to serve the best interests of the child and require mutual agreement from both parents.
The Court Order for Child Custody is similar in its purpose to the Acknowledgment of Paternity. This court document legally defines the custody arrangement for the child, establishing who has the right to make decisions regarding the child’s welfare. Just as the Acknowledgment formalizes the relationship between the child and the parents, a custody order formalizes the arrangement for the child’s living situation and care.
The Child Support Order is another related document. It establishes the financial obligations of the non-custodial parent. Similar to the Acknowledgment of Paternity, which confirms the father’s legal status, a Child Support Order ensures that both parents are contributing financially to their child’s upbringing. Both documents are critical for the child’s welfare and require legal validation.
The Adoption Agreement is also similar, as it legally establishes a parent-child relationship. While the Acknowledgment of Paternity confirms biological parentage, an Adoption Agreement creates a new legal relationship, often severing ties with the biological parents. Both require thorough documentation and legal processes to ensure the child’s rights are protected.
The Declaration of Parentage serves a similar function. This legal document is used to establish a parent-child relationship when parents are not married. Like the Acknowledgment of Paternity, it affirms the legal status of the parents and their rights and responsibilities towards the child. Both documents are essential for securing the child’s legal identity and parental support.
Lastly, the Medical History Form is related in that it collects information about the parents’ medical backgrounds. This information is crucial for the child’s health care needs. While the Acknowledgment of Paternity establishes legal rights, the Medical History Form ensures that the child receives appropriate medical care based on their family history. Both documents contribute to the child’s well-being and future health considerations.
Key takeaways
- Purpose: The Arizona Paternity form is used to establish legal paternity for children born out of wedlock.
- Eligibility: This form is not valid if the mother was married at the time of the child's birth or during the ten months prior, unless a Waiver of Paternity Affidavit is included.
- Completion Guidelines: Use only black ink. Do not make corrections on the form. If an error occurs, request a new form.
- Signatures: Both parents must sign the form in the presence of a witness or notary public. Valid identification is required.
- Multiple Births: A separate form must be filled out for each child in cases of multiple births.
- Child's Name Changes: After the child is three months old, only the last name can be changed using this form; other changes must go through the Office of Vital Records.
- Submission: Mail all pages of the completed form to the specified address, excluding the instruction page.
Common mistakes
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Using the wrong ink color: Always use black ink. Any other color will lead to rejection of the form.
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Making corrections: Do not cross out or erase any information. If a mistake is made, request a new form.
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Leaving blanks: Every box must be filled out completely. Incomplete forms can cause delays.
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Not signing in front of a witness: Signatures must be witnessed or notarized. Failing to do so will invalidate the form.
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Using nicknames: Only legal names should be used. Ensure the names match those on official documents.
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Submitting incomplete acknowledgments: If both parents sign separate forms, ensure all information is identical on each.
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Changing the child’s name incorrectly: After three months of age, only the last name can be changed using this form.
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Not returning all pages: Ensure you send all pages of the acknowledgment, excluding the instruction page.
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GO TO FORM
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Division of Child Support Services
ACKNOWLEDGMENT OF PATERNITY
En Español
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. §
COMPLETION
•Read the “Acknowledgment of Paternity”
•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
Acknowledgment.
•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 official documents.
•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.
DEFINITIONS
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
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ACKNOWLEDGMENT OF PATERNITY |
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CHILD’S NAME (First, Middle, Last, Suffix) AS IT APPEARS ON THE BIRTH CERTIFICATE |
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HOW YOU WANT THE CHILD’S NAME TO APPEAR ON THE BIRTH CERTIFICATE |
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IF THE CHILD’S NAME HAS NOT CHANGED, PLEASE PRINT THE CHILD’S NAME AS IT APPEARS ON THE ORIGINAL BIRTH CERTIFICATE |
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MOTHER’S INFORMATION |
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BIRTHDATE (MM/DD/YYYY) |
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PLACE OF BIRTH (City, State) |
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ADDRESS: (Street, Apt. No., City, State, ZIP) |
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FATHER’S INFORMATION |
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FIRST NAME |
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PLACE OF BIRTH (City, State) |
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ADDRESS: (Street, Apt. No., City, State, ZIP) |
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OCCUPATION |
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The mother was legally married at the time of conception and/or birth of the child. |
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A Waiver of Paternity Affidavit completed by |
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A court order or decree of dissolution which rebuts paternity is attached. |
the present/former husband is attached. |
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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.
SIGNATURE OF MOTHER (Sign only in presence of Witness) |
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SIGNATURE OF FATHER (Sign only in presence of Witness) |
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SIGNATURE OF WITNESS (TO BE COMPLETED BY THE [Check one]:
HOSPITAL |
GOVERNMENT AGENCY |
OTHER) |
SIGNATURE OF WITNESS (TO BE COMPLETED BY THE [Check one]:
HOSPITAL |
GOVERNMENT AGENCY |
OTHER) |
WITNESS MUST BE AT LEAST 18 YEARS OF AGE AND NOT RELATED BY BLOOD OR MARRIAGE.
PRINTED NAME OF WITNESS |
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NOTARY SECTION |
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TO BE COMPLETED BY A NOTARY PUBLIC ONLY IF NOT WITNESSED ABOVE |
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State of Arizona, County of |
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State of Arizona, County of |
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Subscribed and sworn or affirmed before me |
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Subscribed and sworn or affirmed before me |
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NOTARY PUBLIC |
NOTARY PUBLIC |
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PLACE NOTARY SEAL HERE |
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PLACE NOTARY SEAL HERE |
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My Commission expires |
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My Commission expires |
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Check this box if form completed at the hospital. |
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Paternity Date |
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ALL COPIES OF THIS DOCUMENT MUST HAVE ORIGINAL SIGNATURES |
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For Office Use Only |
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THIS ACKNOWLEDGMENT IS BEING SIGNED VOLUNTARILY WITH NO THREAT OR HARM OR DURESS |
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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. §
I understand that if the current/former husband’s location is unknown to the mother, the mother will be required to apply for
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. §
I understand that upon the determination of paternity, both parents have a legal obligation to support their child pursuant to A.R.S. §
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. §
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. §
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. §
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. §
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
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
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) |
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BIRTHDATE |
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MOTHER’S NAME (Last, First, M.I.) |
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FATHER’S NAME (Last, First, M.I.) |
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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 |
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Professional degree (e.g. MD, DDS, DVM, LLB, JD ) |
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FATHER’S RACE (Check All That Apply) |
White
Black, African American
American Indian or Alaska Native (*see list below) Primary or Enrolled tribe:
Additional Tribe:
Additional Tribe:
Additional Tribe: Asian Indian Chinese Filipino Japanese Korean
Other Asian
Specify:
Specify:
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
Specify:
Specify:
Other
Specify:
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
Ak Chin Indian Community |
Navajo Tribe |
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Camp Verde Yavapai Apache |
Pascua Yaqui |
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Cocopah Tribe |
Prescott Yavapai Indian Community Quechan Tribe |
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Colorado River Indian Tribes |
Salt River Indian Community (Pima) |
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Fort Mohave Tribe |
San Carlos Apache Tribe |
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Ft. McDowell |
San Juan Southern Paiute Band |
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(Pima) Havasupai Tribe |
Tohono O’Odham Tribe (Papago) |
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Hopi Tribe |
Tonto Apache |
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Hualapai Tribe |
White Mountain Apache Tribe (Fort Apache) |
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Kaibab Band of Paiute Indian |
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FATHER’S HISPANIC ORIGIN (Check One) |
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No, not Spanish, Hispanic or Latino |
Dominican, Columbian) |
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Yes, Mexican, Mexican American, Chicano |
Specify: |
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Yes, Puerto Rican |
Specify: |
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Yes, Cuban |
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Unknown |
Refused |
Not Obtainable |
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Yes, other Spanish/Hispanic/Latina (e.g. Spaniard, Salvadoran, |
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ARIZONA DEPARTMENT OF ECONOMIC SECURITY |
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Division of Child Support Services (División de Servicio de Sustento para Menores) |
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RECONOCIMIENTO DE PATERNIDAD |
LEA DETENIDAMENTE TODAS LAS INSTRUCCIONES Y DESPRENDA ESTA HOJA ANTES DE LLENAR EL FORMULARIO
El propósito de este formulario es reconocer paternidad para un niño nacido a una madre soltera. Conforme a A.R.S.
PARA LLENAR EL FORMULARIO
•Lea el “Reconocimiento de Paternidad”
•Use sólo TINTA NEGRA. NO SE ACEPTARÁ tintas en colores. Escriba a máquina o con letra de molde toda la información reque- rida excepto donde haya que firmar. La traducción al español en la última página es sólo para referencia; sírvase llenar el lado en inglés.
•NO HAGA CORRECCIONES EN EL FORMULARIO. Formularios con tachones, borraduras, alteraciones etc. invalidarán el Reco- nocimiento. NO PRESENTE UN RECONOCIMIENTO QUE CONTENGA TALES MODIFICACIONES. Si comete un error, pida otro formulario y empiece de nuevo.
•Llene cada uno de los espacios o cajas del formulario. La información incompleta o incorrecta puede causar demoras en el registro del Reconocimiento.
•En casos de nacimientos múltiples hay que llenar un Reconocimiento individual para cada niño.
•El reconocimiento se habrá de firmar ante un testigo o notario público. La madre y el padre tienen que firmar sus nombres en todas las copias del formulario y cada una de las firmas tiene que ser certificadas ante un testigo o notario público. La madre y el padre tienen que mostrar identificación apropiada y válida al testigo o notario. Ambos padres deberán utilizar solamente sus nombres legales. NO SE PODRÁ utilizar apodos, nombres acortados, etc. Su nombre legal es el que aparece en su certificado de nacimiento u otros documentos oficiales.
•Si ambos padres no pueden firmar el Reconocimiento a la vez, use Reconocimientos separados. Cuando firmen Reconocimientos separados, la información sobre el niño tiene que ser idéntica en ambos formularios. Todos los espacios se tienen que llenar, y presentarse ambos Reconocimientos simultáneamente.
•Si usted va a cambiar el nombre del niño, después de los 3 meses de edad se puede cambiar solamente el apellido del niño usando este formulario. Se debe pedir cualquier otro cambio por la oficina de estadísticas demográficas
•Si llenan este Reconocimiento fuera del hospital, recuerde certificar las firmas ante un notario público o un testigo calificado. Un testigo calificado tiene que tener por lo menos 18 años de edad y no tener parentesco sanguíneo o por matrimonio con ninguno de los padres. Los notarios públicos están listados en el directorio telefónico. DEVUELVA TODAS LAS PÁGINAS DEL RECONOCI- MIENTO (excepto las instrucciones para llenarlo). Envíe el documento completo a:
DCSS Hospital Paternity Program – HPP
PO BOX 64533
Phoenix, AZ 85082
•Si requiere una copia del certificado de nacimiento, envíe su dinero de solicitud, también con la solicitud por certificado de naci- miento, a la dirección listada en la solicitud por certificado de nacimiento. NO envíe ningún dinero al Programa de Paternidad en los Hospitales.
DEFINICIONES
DES - Departamento de Seguridad Económica
DHS - Departamento de Servicios de Salud
DCSS - División de Servicio de Sustento para Menores
¿CÓMO SE APROVECHARÁ SU HIJO SI USTED FIRME ESTE FORMULARIO?
•Cada niño tiene derecho de conocer a su madre y padre y sacar provecho de una relación con ambos padres.
•Su hijo tendrá tanto una madre como un padre legal.
•Su hijo tiene derecho de asistencia financiera de ambos padres.
•Será más fácil para su hijo obtener las historias médicas de ambos padres y aprovecharse la cobertura médica disponible a usted.
•Será más fácil para su hijo heredar a través de usted y recibir beneficios tales como beneficios para dependientes o sobrevivientes de la Administración de Veteranos o la Administración de Seguro Social.
Programa y Empleador con Igualdad de Oportunidades • Bajo los Títulos VI y VII de la Ley de los Derechos Civiles de 1964 (Títulos VI y VII) y la Ley de Estadounidenses con Discapacidades de 1990 (ADA por sus siglas en inglés), Sección 504 de la Ley de Rehabilita- ción de 1973, Ley contra la Discriminación por Edad de 1975 y el Título II de la Ley contra la Discriminación por Información Genética (GINA por sus siglas en inglés) de 2008; el Departamento prohíbe la discriminación en la admisión, programas, servicios, actividades o empleo basado en raza, color, religión, sexo, origen, edad, discapacidad, genética y represalias. Para obtener este documento en otro formato u obtener información adicional sobre esta política, llame al
Form in English
ARIZONA DEPARTMENT OF ECONOMIC SECURITY |
NÚM. Remueva el Formulario |
RECONOCIMIENTO DE PATERNIDAD |
FAVOR DE ESCRIBIR CLARAMENTE. Llene con TINTA NEGRA. NO ALTERE ESTE DOCUMENTO LEGAL
INFORMACIÓN DEL NIÑO
NOMBRE DEL NIÑO (Primer nombre, segundo, apellido, sufijo) COMO APARECE EN EL CERTIFICADO DE NACIMIENTO
FECHA DE NACIMIENTO (Mes/día/año) |
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MALE |
FEMALE LUGAR DE NACIMIENTO CIUDAD |
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CONDADO |
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ESTADO |
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HOSPITAL |
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CÓMO DESEA QUE APAREZCA EL NOMBRE DEL NIÑO EN EL CERTIFICADO DE NACIMIENTO
SI EL NOMBRE DEL NIÑO NO HA CAMBIADO, ESCRIBA EL NOMBRE TAL COMO APARECE EN EL CERTIFICADO DE NACIMIENTO ORIGINAL
PRIMER NOMBRE |
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SEGUNDO NOMBRE |
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APELLIDO |
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SUFIJO (Jr., II) |
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INFORMACIÓN DE LA MADRE |
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PRIMER NOMBRE |
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SEGUNDO NOMBRE |
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APELLIDO |
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NOMBRE DE SOLTERA |
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FECHA DE NACIMIENTO (Mes/día/año) |
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NÚM. DE SEGURO SOCIAL |
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CÓDIGO DE ÁREA Y TELÉFONO |
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LUGAR DE NACIMIENTO (Ciudad, estado) |
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PAÍS DE NACIMIENTO |
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DOMICILIO (Calle, núm. de apartamento, ciudad, estado, código postal ZIP) |
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EMPLEADOR |
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OCUPACIÓN |
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INFORMACIÓN DEL PADRE |
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PRIMER NOMBRE |
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SEGUNDO NOMBRE |
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APELLIDO |
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FECHA DE NACIMIENTO (Mes/día/año) |
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NÚM. DE SEGURO SOCIAL |
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CÓDIGO DE ÁREA Y TELÉFONO |
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LUGAR DE NACIMIENTO (Ciudad, estado) |
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PAÍS DE NACIMIENTO |
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DOMICILIO (Calle, núm. de apartamento, ciudad, estado, código postal ZIP) |
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EMPLEADOR |
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OCUPACIÓN |
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La madre estaba casada legalmente al momento de la concepción/el nacimiento del niño. Adjunto hay una orden del tribunal o decreto de disolución que refuta la paternidad.
Adjunto hay una renuncia de Affidávit de Paternidad llenado por del esposo actual/anterior.
Este Reconocimiento de Paternidad se firma voluntariamente, sin amenaza, ni perjuicio ni por coacción. He recibido aviso escrito y verbal, y he leído el AVISO DE LAS OPCIONES, LAS CONSECUENCIAS LEGALES Y LOS DERECHOS Y RESPONSABILIDADES. Comprendo mis opciones, las consecuencias legales y los derechos y las responsabilidades. Juro y afirmo bajo pena de perjurio conforme a A. .S.
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FIRMA DE LA MADRE |
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FECHA (Mes/día/año) |
FIRMA DEL PADRE |
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FECHA (Mes/día/año) |
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(Firma solamente en presencia de un Testigo) |
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(Firma solamente en presencia de un Testigo) |
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NO FIRME AQUÍ |
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FIRMA DEL TESTIGO (SERÁ LLENADO POR [Marque uno] : |
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FIRMA DEL TESTIGO (SERÁ LLENADO POR [Marque uno] : |
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HOSPITAL |
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GUBERNAMENTAL |
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OTRO) |
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HOSPITAL |
AGENCIA GUBERNAMENTAL |
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OTRO) |
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AGENCIAINVALIDO PARA REGISTRO |
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EL TESTIGO HABRÁ DE TENER POR LO MENOS 18 AÑOS DE EDAD Y NO TENER PARENTESCO SANGUÍNEO NI POR MATRIMONIO. |
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NOMBRE DEL TESTIGO CON LETRA DE MOLDE |
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NOMBRE DEL TESTIGO CON LETRA DE MOLDE |
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DIRECCIÓN |
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DIRECCIÓN |
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DIRECCIÓN |
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DIRECCIÓN |
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SECCIÓN PARA EL NOTARIO |
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LA LLENARÁ UN NOTARIO PÚBLICO SOLAMENTE EN AUSENCIA DE TESTIGOS ARRIBA |
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Estado de Arizona, condado |
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Estado de Arizona, condado |
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Subscrito y jurado o afirmado ante mí |
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Subscrito y jurado o afirmado ante mí |
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este |
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día de |
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este |
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NOTARIO PÚBLICO |
NOTARIO PÚBLICO |
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SELLO DEL NOTARIO AQUÍ |
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SELLO DEL NOTARIO AQUÍ |
Mi comisión termina |
Mi comisión termina |
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Marque esta cajita se llenó el formulario en el hospital. |
Fecha de paternidad |
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TODAS LAS COPIAS DE ESTE DOCUMENTO DEBEN TENER FIRMAS ORIGINALES. |
Sólo para uso de oficina |
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ESTE DOCUMENTO DE PATERNIDAD SE FIRMA VOLUNTARIAMENTE, SIN AMENAZA, PERJUICION NI COACCIÓN
AVISO DE LAS OPCIONES, LAS CONSECUENCIAS LEGALES,
LOS DERECHOS Y LAS RESPONSABILIDADES
LEA ESTA INFORMACIÓN DETENIDAMENTE ANTES DE FIRMAR EL FORMULARIO
El propósito de este formulario es reconocer paternidad para un niño nacido a una madre soltera.
Nosotros, la madre biológica y el padre biológico, declaramos que la información provista es cierta y correcta. Reconoce- mos que el padre nombrado es el único padre posible del niño nombrado.
Si la madre del niño estuvo casada en cualquier momento durante los 10 meses inmediatamente anteriores al nacimiento del niño o si el nacimiento del niño ocurrió dentro de 10 meses de haber terminado el matrimonio por causa de muerte, anulación, declaración de invalidez o disolución del matrimonio, o después que el tribunal haya registrado un decreto de separación legal. Según A.R.S. §
Entiendo que si la madre no sabe el paradero del esposo actual/anterior, la madre tendrá que solicitar servicios de
Entiendo que al firmar este reconocimiento cedemos nuestro derecho de una audiencia para determinar paternidad ante un tribunal, así como nuestro derecho de pruebas genéticas para determinar la paternidad para este niño.
Entiendo además que quizá tengamos derecho de rescindir o recusar este reconocimiento conforme a A.R.S. §
Entiendo que al determinar la paternidad, ambos padres tienen una obligación legal de mantener a su hijo conforme a A.R.S. §
Entiendo que esta determinación de paternidad no es una orden de custodia pero sirve como base para determinar asuntos relacionados con la custodia y las visitas, y proporciona a los padres todos los derechos y responsabilidades provistos por la ley de Arizona.
Entiendo que cualquiera de los padres tiene derecho de cancelar el Reconocimiento de Paternidad llenando un Afidávit de Rescisión de Paternidad dentro de 60 días desde la fecha de la última firma preparada ante un testigo/notario público en el Reconocimiento, y enviándolo al Programa de Paternidad en Hospitales conforme a A.R.S. §
Un Reconocimiento de Paternidad voluntario registrado con el Departamento de Seguridad Económica o el Depar- tamento de Servicios de Salud tiene el mismo peso y efecto como un fallo del Tribunal Superior conforme a A.R.S. §
Declaro además que esta declaración sea hecha para ser registrada con el Secretario del Tribunal Superior, el Departa- mento de Seguridad Económica o el Departamento de Servicios de Salud conforme a A.R.S. §
Entiendo que si DES lo estima apropiado, este reconocimiento se podrá utilizar para obtener una orden de paternidad en cualquier condado con jurisdicción en Arizona.
Entiendo que conforme a 42 USC § 652(a) (7) y 666(a) (5) (IV) debo proporcionar mi número de Seguro Social. DES/ DCSS utilizará esta información para establecer paternidad y, si es apropiado, para establecer y hacer cumplir una orden de alimentos para menores.
Juro o afirmo bajo pena de perjurio conforme a A.R.S. §
¿QUÉ SIGNIFICA SI YO FIRME ESTE FORMULARIO?
Mediante su firma en este Reconocimiento de Paternidad usted legalmente establece la paternidad de su niño. La pater- nidad significa que usted es el padre legal del niño.
El firmar este formulario es voluntario. Usted no debe firmar este formulario si le han amenazado o coaccionado.
Este Reconocimiento no le otorga automáticamente al padre los derechos de custodia o visitas, pero él puede utilizarlo para pedir esos derechos en el tribunal.
Cualquiera de los padres puede rescindir este formulario dentro de 60 días de la última firma en el formulario firmando un Afidávit de Rescisión de Paternidad
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
(Departamento de Sanidad de Arizona)
Office of Vital Records (Oficina de Registro Civil)
INFORMACIÓN ADICIONAL SOBRE EL PADRE QUE FIGURA EN EL
RECONOCIMIENTO DE PATERNIDAD (para el trámite de partida de nacimiento)
La Oficina de Registro Civil del Departamento de Sanidad de Arizona tiene la obligación de recabar y transmitir la información al Centro Nacional de Estadísticas de Sanidad del Departamento de Sanidad y Servicios Humanitarios (NCHS por sus siglas en inglés). Por favor proporcione los datos que se solicitan a continuación, los que se recaban con fines estadísticos. Gracias de antemano por proporcionar la información.
NOMBRE DEL NIÑO (apellido, nombre, sufijo) |
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FECHA DE NACIMIENTO |
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NOMBRE DE LA MADRE |
NOMBRE DEL PADRE |
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(apellido, nombre, inicial del segundo nombre) |
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(apellido, nombre, inicial del segundo nombre) |
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EDUCACIÓN DEL PADRE (marque una)
¿Cuál es el nivel más alto de educación que usted obtuvo al momento del nacimiento del niño? Marque una de las casillas que mejor des- criba su educación. Si en la actualidad usted está matriculado, marque la casilla que indica el grado anterior o el título más alto obtenido.
8.ᵃᵛᵒ grado o menos |
Diploma por dos años de estudios superiores (ej. AA, AS) |
9.ᶰᵒ – 12.ᵃᵛᵒ grado, no diploma |
Licenciatura (ej. BA, AB, BS ) |
Graduado de bachillerato o certificado de GED |
Maestría (ej. MA, MS MEng, Med, MSW, MBA) |
Algunos créditos de educación superior, pero sin título |
Doctorado (ej. PhD, EdD) o Profesional (ej. MD, DDS, DVM, LLB, JD) |
RAZA DEL PADRE (marque todo lo que corresponda)
Blanco
Negro, afroestadounidense
Amerindio o nativo de Alaska (*vea la lista a continuación) Tribu principal o inscrita:
Tribu adicional: Tribu adicional: Tribu adicional:
Indio asiático
Chino
Filipino
Japonés
Coreano
Otros asiáticos
Especifique:
Especifique:
Hawaiano
Guameño o chamorro
Samoano
Otros isleños de la Polinesia
Especifique:
Especifique:
Otros
Especifique:
Especifique:
Desconocido |
Rehúsa |
No se puede obtener |
*Por favor, seleccione de la siguiente lista la(s) tribu(s) apropiada(s) de Arizona con la(s) que el padre tiene afiliación y escriba el nom- bre de la tribu en el espacio que se da a continuación. Si el padre tiene afiliación a una tribu que no es de Arizona, por favor escriba “otros” en el espacio correspondiente o el nombre de la tribu que no pertenece a Arizona.
Comunidad Indígena Ak Chin |
Tribu Navajo |
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Camp Verde Yavapai Apache |
Pascua Yaqui |
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Tribu Cocopah |
Comunidad Indígena Prescott Yavapai |
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Tribus Indígenas de Colorado River |
Tribu Quechan |
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Tribu Fort Mohave |
Comunidad Indígena Salt River (Pima) |
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Comunidad |
Tribu San Carlos Apache |
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Comunidad Indígena Gila River (Pima) |
San Juan Southern Paiute Band |
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Tribu Havasupai |
Tribu Tohono O’Odham (Papago) |
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Tribu Hopi |
Tonto Apache |
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Tribu Hualapai |
Tribu White Mountain Apache (Fort Apache) |
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Kaibab Band de Indígenas Paiute |
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ORIGEN HISPÁNICO DEL PADRE (marque uno) |
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No, no soy español, hispánico o latino |
dominicano, colombiano) |
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Sí, soy mejicano, mejicano americano, chicano |
Especifique: |
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Sí, soy portorriqueño |
Especifique: |
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Sí, soy cubano |
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Desconocido |
Rehúsa |
No se puede obtener |
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Sí, soy otro español/hispánico/latino (ej. español, salvadoreño, |
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Form Breakdown
| Fact Name | Description |
|---|---|
| Purpose | This form is used to acknowledge paternity for a child born out of wedlock. |
| Eligibility | The form is not applicable if the mother was married at the time of birth or within ten months preceding the birth, unless a Waiver of Paternity Affidavit is included. |
| Completion Instructions | Only black ink should be used. All required information must be typed or printed clearly, and no corrections are allowed. |
| Witness Requirement | The Acknowledgment must be signed in the presence of a witness or notary public, and valid identification must be shown. |
| Multiple Births | A separate Acknowledgment form is required for each child in cases of multiple births. |
| Child’s Name Change | After the child is three months old, only the last name can be changed using this form; other name changes must go through the Office of Vital Records. |
| Legal Consequences | Signing this form legally establishes paternity, which includes obligations for financial support and rights to inherit. |
| Rescission Rights | Either parent can rescind the acknowledgment within 60 days by submitting an Affidavit of Paternity Rescission. |
| Governing Laws | This form is governed by Arizona Revised Statutes (A.R.S.) § 25-814 and § 25-812. |