Name: Mailing Address: Daytime Telephone: Representing Self without an attorney IN THE SUPERIOR COURT OF ARIZONA, YAVAPAI COUNTY DO Petitioner vs. APPLICATION FOR THE ISSUANCE OF A WARRANT TO TAKE PHYSICAL CUSTODY OF MINOR CHILD(REN) Respondent Petitioner presents this Application for the Issuance of a Warrant to Take Physical Custody of Minor Child(ren) and alleges, 1. An emergency exists and the Order must be entered immediately to avoid irreparable harm because: [ ] The child(ren) named in is/are [ ] imminently likely to suffer serious physical harm AND/OR [ ] be removed from Arizona. Facts supporting this claim 2. [ ] Advance notice of this Order should not be required to be given to the other party, or his or her attorney or others entitled to prior notice, because [ ] to do so would result in immediate and irreparable harm to _______________________ [ ] Other: Facts supporting this claim 3. [ ] Authorization for law enforcement officers to enter private property to take physical custody of the child(ren) is necessary because no less intrusive remedy is effective. Facts supporting this claim 4. [ ] Exigent circumstances require authorization for law enforcement officers to make a forcible entry at any hour to take physical custody of the child(ren). Facts supporting this claim Superior Court of Arizona in Yavapai County January 2006 Page 1 of 2 Use only most current version American LegalNet, Inc. www.FormsWorkflow.com 5. This Order is in the best interests of, and covers the following child(ren): Date of Birth Date of Birth Date of Birth Name Name Name OATH AND VERIFICATION State of Arizona County of Yavapai ) ) I, , being duly sworn and under oath, state that I have read this Application and the contents are true and correct to the best of my knowledge, information and belief. I understand that if the judicial officer finds that I did file this for an improper purpose, contempt or other sanctions may be ordered against me, including assessing me for any and all reasonable costs, attorney fees, or other expenses associated with the improper filing. SIGNED SUSCRIBED AND SWORN to before me this , by day of , 20 My commission expires: Notary Public Superior Court of Arizona in Yavapai County January 2006 Page 2 of 2 Use only most current version American LegalNet, Inc. www.FormsWorkflow.com