When you file this with this court, do not include any of the enclosures or attachments. Those just go to the other party. Person Filing: Mailing Address: City, State, Zip: Phone Number: Representing Self COCONINO COUNTY SUPERIOR COURT Petitioner's Name on the Petition for divorce, legal separation, or parenting time: Case Number: DO DISCLOSURE STATEMENT Respondent's Name: For Parenting Time, Legal DecisionMaking, and Child Support Today's Date: My Name: Witnesses: I plan to bring these witnesses if there's a trial in this case: Name: Address: Detailed Summary of What They'll Say in Court: Phone Number: Name: Address: Phone Number: Page 1 of 4 Revised November 2014 � 2014 Coconino County Law Library American LegalNet, Inc. www.FormsWorkFlow.com Detailed Summary of What They'll Say in Court: Expert Witnesses: I plan to bring these expert witnesses if there's a trial in this case: Name: Address: What Makes Them an Expert: Detailed Summary of What They'll Say in Court: Phone Number: Have they prepared a report about what they'll say? [ ] Yes [ ] No Name of Person Who Has the Report: Address of Person Who Has the Report: Name: Address: What Makes Them an Expert: Detailed Summary of What They'll Say in Court: Phone Number: Have they prepared a report about what they'll say? [ ] Yes [ ] No Name of Person Who Has the Report: Address of Person Who Has the Report: Page 2 of 4 Revised November 2014 � 2014 Coconino County Law Library American LegalNet, Inc. www.FormsWorkFlow.com Children's Primary Residence, and Legal Decision-Making About the Children: Do you and the other parent agree about the children's primary residence and legal decision-making about the children? [ ] Yes [ ] No If No, fill out this section, and enclose the items listed in this section. If Yes, skip this section. My Treatment Providers: During the five years before the Petition was filed, I was treated for psychiatric or psychological issues, anger management, substance abuse or domestic violence by: Treatment Provider's Name: Treatement Provider's Address: Start Date of Treatment: Treatment Provider's Name: Treatement Provider's Address: Start Date of Treatment: End Date of Treatment: End Date of Treatment: My Spouse's Treatment Providers: During the five years before the Petition was filed, my spouse was treated for psychiatric or psychological issues, anger management, substance abuse or domestic violence by: Treatment Provider's Name: Treatement Provider's Address: Start Date of Treatment: Treatment Provider's Name: Treatement Provider's Address: Start Date of Treatment: I'm Enclosing The Following: End Date of Treatment: End Date of Treatment: A copy of any past or current protective order, and the petition that asked for it, involving me or my spouse or a member of one of our households. The date, description, location, and documentation of any criminal charge against or conviction of me or my spouse or a member of one of our households during the ten years before the Petition was filed. The date, description, location, and documentation of any Child Protective Services investigation or proceeding involving me or my spouse or a member of one of our households during the ten years before the Petition was filed. Page 3 of 4 Revised November 2014 � 2014 Coconino County Law Library American LegalNet, Inc. www.FormsWorkFlow.com Child Support: Do you and the other parent agree about child support? [ ] Yes [ ] No If No, I'm enclosing the following: A completed Affidavit of Financial Information Proof of my income from all sources, including complete tax returns, W-2 forms, 1099 forms, and K-1 forms, for the past two completed calendar years, and year-to-date income information for the current calendar year, including, but not limited to, year-to-date pay stub, salaries, wages, commissions, bonuses, dividends, severance pay, pensions, interest, trust income, annuities, capital gains, social security benefits, worker's compensation benefits, unemployment insurance benefits, disability insurance benefits, recurring gifts, prizes, and spousal maintenance. Proof of all medical, dental, and vision insurance premiums I've paid for any child listed in the Petition. Proof of any child care expenses I've paid for any child listed in the Petition. Proof of any expenses I've paid for private or special schools or other particular education needs for any child listed in the Petition. Proof of any expenses I've for the special needs of a gifted or handicapped child listed in the Petition. Proof of court-ordered child support and spousal maintenance I've paid in any other court case. Future Information and Documents: If I learn about new or different information or documents about these topics in the future, I will mail or hand-deliver a copy of it to the other party by 30 days after I learn about it. My Signature: Page 4 of 4 Revised November 2014 � 2014 Coconino County Law Library American LegalNet, Inc. www.FormsWorkFlow.com