FOR CLERK’S USE ONLY Name of Person Filing: ___________________________________ Mailing Address: ___________________________________ City, State, Zip Code: ___________________________________ Daytime Phone Number: ___________________________________ Evening Phone Number: ___________________________________ ATLAS Number (if Applicable):_______________________________ State Bar Number (If Applicable):_____________________________ Self Petitioner Respondent Representing: SUPERIOR COURT OF ARIZONA MOHAVE COUNTY _______________________________________ Petitioner/Plaintiff _______________________________________ Respondent/Defendant Case Number ______________________ PROPOSED PATERNITY RESOLUTION STATEMENT OF: FATHER MOTHER The undersigned party provides the following specific positions on each of the issues in this case (BE SPECIFIC): 1. IV-D Case: I receive or have received public assistance that may include AFDC, TANF, or AHCCCS for my children or me. I have a case with the Division of Child Support Enforcement. 2. Custody: The other parent and I have the following natural or adopted children in common: Child(ren)’s Name(s) _________________________________________________ _________________________________________________ _________________________________________________ Mother OR The children should live primarily with Mother Father as follows (check all that apply): Ƒ Date of Birth _______________ _______________ _______________ Age _________ _________ _________ Father and have parenting time with In accordance with County Guidelines for reasonable parenting time. Model Parenting Time Plans (describe plan)__________________________________________. Every other weekend from: a.m. p.m. to _______________ at _________ a.m. p.m. _______________ at _________ One-half of the holidays on an alternating basis. For ________ weeks in the summer from _______________ to ______________(inclusive). Spring Break from school. Other: ___________________________________________________________________ _________________________________________________________________________ 11/7/06 Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com Case No._________________________ Ƒ Mother or Ƒ Father should have sole legal custody, OR Ƒ Mother and Father should have joint legal custody. 3. Child Support: The financial factors necessary to calculate child support under the Arizona Child Support Guidelines are as follows (complete in full): Father’s gross monthly income: $________________ Mother’s gross monthly income: $________________ Father has _______ other child(ren) not listed above who live(s) in his household. Father has _______ other child(ren) not listed above for whom he pays court-ordered child support in the amount of $ _____________ per month. Mother has _______ other child(ren) not listed above who live(s) in her household. Mother has _______ other child(ren) not listed above for whom she pays court-ordered child support in the amount of $ _____________ per month. Medical Insurance should be paid by [ ] Mother [ ] Father. Monthly cost for the child(ren) is $ _____________. Ƒ Dental insurance should be paid by Ƒ Mother Ƒ Father. Monthly cost for the child(ren) is $ _______________. Ƒ Vision insurance should be paid by Ƒ Mother Ƒ Father. Monthly cost for the child(ren) is $ _______________. Monthly child care costs for _______ child[ren] is $ _____________. Extra education expenses or extraordinary child adjustments: I believe the court should add the following to the child support calculation (leave blank if none claimed): Description of expense ________________________________________________________ ___________________________________________________________ ___________________________________________________________ Monthly Amount $___________________ $___________________ $___________________ Uninsured medical/dental/vision expenses should be paid: Pro rata based upon each party’s income as provided in the guidelines; or Other: _______% paid by Father and _______% paid by Mother. Tax Exemptions for the child(ren) should be divided (check one): Pro rata based upon each party’s income as provided in the guidelines; or Other: _________________________________________________________________ Past support should be paid by Ƒ Mother Ƒ Father for the period of __________________ in the amount of $ _____________. ____________through Direct payments for support have been Ƒ received by me Ƒ paid by me for the period of __________________ through ______________ in the amount of $ _____________. Past medical expenses have been incurred by me (and not reimbursed by insurance) for the period of ________________ through ____________ in the amount of $ ______________ and the other parent should be ordered to reimburse me for _______% of those expenses. Expenses for pregnancy, childbirth, and genetic testing have been incurred by me (and not reimbursed by insurance) in the amount of $_____________ and the other parent should be ordered to reimburse me for _______% of those expenses. 4. 11/7/06 Attorneys’ Fees: If the case is settled today, I want the Court to order (choose one): Each party to pay his or her own attorneys’ fees and costs. Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com Case No.___________________________ Mother to pay $_____________ of my attorneys’ fees and costs within _______ days. Father to pay $_____________ to other party for attorneys’ fees and costs within _______ days. 5. Name Change: I want the child(ren)’s names to be changed as follows: ________________________________________________________________________________ ________________________________________________________________________________ 6. Other Issues: Briefly state the other issues that you believe must be resolved to fully settle this case: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 7. Settlement: I understand that I am required to personally meet and confer with the opposing party and their counsel at least five court days before my court date to resolve as many issues as possible unless there is a current court order prohibiting contact or a significant history of domestic violence between us. I verify that the above statements are true based on my best information and belief and I am willing to settle and resolve this case based upon my positions as provided above. I will be prepared to show documentation to support my position at the time of the conference or hearing. _______________________________ Date 11/7/06 ___________________________________________ Mother Father Signature of Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com