SUPERIOR COURT OF ARIZONA IN MARICOPA COUNTY For Clerk's Use Only In the Matter of: Case Number CV: Person whose birth certificate is to be corrected (as listed on the Petition to Amend) ORDER AMENDING BIRTH CERTIFICATE OF A MINOR A.R.S. § 36-337 THE COURT FINDS: 1. This case has come before this Court to correct errors or omissions on the birth certificate of the person named above. 2. Pursuant to A.R.S. §36-337, this Court has jurisdiction to order that the birth record be amended. 3. Good cause exists to grant the petition to amend the birth certificate as requested. 4. The name, date and place of birth of the person whose birth record is to be corrected appears on his or her Arizona birth certificate as follows: THE PRESENT NAME APPEARING ON THE SUBJECT BIRTH CERTIFICATE: First Middle Last Date of Birth: Month Day Year Place of Birth: City State Nation Page 1 of 3 © Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED ORD CVABM81f-081010 American LegalNet, Inc. www.FormsWorkFlow.com Case No.________________ 5. The Court finds information indicated below to be incorrect on the present birth certificate: PETITIONER / MINOR CHILD's NAME DATE of BIRTH PLACE of BIRTH OTHER: MOTHER's NAME DATE of BIRTH PLACE of BIRTH OTHER: FATHER's NAME DATE of BIRTH PLACE of BIRTH OTHER: THE COURT ORDERS: 1. THE INFORMATION ON THE SUBJECT BIRTH CERTIFICATE SHALL BE CHANGED REGARDING: A. Petitioner or Minor Child's (or protected or incapacitated adult's) NAME, which shall be corrected to read EXACTLY as written below: DATE of BIRTH PLACE of BIRTH OTHER: OTHER: shall be corrected to: shall be corrected to: shall be corrected to: shall be corrected to: B. FATHER'S: NAME, which shall be corrected to read EXACTLY as written below: DATE of BIRTH PLACE of BIRTH OTHER: OTHER: shall be corrected to: shall be corrected to: shall be corrected to: shall be corrected to: Page 2 of 3 © Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED ORD CVABM81f-081010 American LegalNet, Inc. www.FormsWorkFlow.com Case No._______________ C. MOTHER'S: NAME, which shall be corrected to read EXACTLY as written below: DATE of BIRTH PLACE of BIRTH OTHER: OTHER: shall be corrected to: shall be corrected to: shall be corrected to: shall be corrected to: 2. THAT THE SUBJECT BIRTH RECORDS BE CHANGED TO CORRECT THE FOLLOWING ERRORS OR OMISSIONS: 3. For a person born in the State of Arizona, the Office of Vital Records is ordered to amend the birth record to reflect the corrected information as ordered above. 4. This Order does not release the Petitioner or protected or incapacitated person or minor child on whose behalf the underlying petition was filed from any obligations incurred or harm any rights of property or action in any previous name. Other orders: 5. DONE IN OPEN COURT: Date Judicial Officer Page 3 of 3 © Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED ORD CVABM81f-081010 American LegalNet, Inc. www.FormsWorkFlow.com