Person Filing: Address (if not protected): City, State, Zip Code: Telephone: Email Address: Lawyer's Bar Number: Representing Self, without a Lawyer or Attorney for Petitioner OR FOR CLERK'S USE ONLY Respondent SUPERIOR COURT OF ARIZONA IN MARICOPA COUNTY In the Matter of: Case Number (Clerk will stamp case # when submitted) DEPENDENCY PETITION A.R.S. � 8-841 (Names of children under 18 years of age) 1. INFORMATION ABOUT ME, the Petitioner: My Name: My Address: Street City State Zip Code My Telephone Number: Home Work Message My relationship to the children: I am a fit and proper person to care for the children. 2. INFORMATION ABOUT THE CHILDREN: Child's Name: Birth date: Gender: Birth date: Gender: Birth date: Gender: Male Female Child's Name: Male Female Child's Name: Male Female � Superior Court of Arizona in Maricopa County - Juvenile Division ALL RIGHTS RESERVED Page 1 of 5 JVD11f 031616 Use current form American LegalNet, Inc. www.FormsWorkFlow.com Case No. INFORMATION ABOUT THE CHILDREN (continued): Address where children are currently living: City Street State Zip Code The children have been living there since (give approximate date): The children are now living in the State of Arizona, Maricopa County: Name(s) of persons currently living with children: Relationship: to Child Relationship: to Child Relationship: to Child Yes No Is any child named above an enrolled member of any Indian Nation or Tribe or eligible to be Yes No enrolled as a member of any Indian Nation or Tribe? If "Yes", what Indian Nation or Tribe? 3. INFORMATION ABOUT THE PARENTS AND CURRENT LEGAL GUARDIANS (IF ANY) OF THE CHILDREN: MOTHER'S Name: Address: Street City State Zip Code Birth Date: FATHER'S Name: Alleged father of the following children: Address: Street City Birth Date: State Zip Code NAME OF OTHER FATHER (IF ANY): Alleged father of the following children: Address: Street City State Birth Date: Zip Code � Superior Court of Arizona in Maricopa County - Juvenile Division ALL RIGHTS RESERVED Page 2 of 5 JVD11f 031616 Use current form American LegalNet, Inc. www.FormsWorkFlow.com Case No. NAME OF OTHER FATHER (IF ANY): Alleged father of the following children: Address: Street City State Birth Date: Zip Code NAME OF CURRENT LEGAL GUARDIAN(S) (IF ANY): Birth Date: Legal guardian of the following children: Address: Street City State Zip Code 4. DEPENDENCY ALLEGATIONS. The Petitioner believes the children are dependent within the provisions of ARS � 8-201.13, because the children are in need of proper and effective parental care and control and has no parent or guardian willing to exercise or capable of exercising such care and control, or whose home is unfit by reason of abuse, neglect, cruelty, or depravity, as follows: A. The MOTHER is unable or incapable of providing care for the children for the following reasons (provide specifics): � Superior Court of Arizona in Maricopa County - Juvenile Division ALL RIGHTS RESERVED Page 3 of 5 JVD11f 031616 Use current form American LegalNet, Inc. www.FormsWorkFlow.com Case No. B. The FATHER is unable or incapable of providing care for the children for the following reasons (provide specifics as to each alleged father): C. The LEGAL GUARDIAN is unable or incapable of providing care for the children for the following reasons (provide specifics as to each legal guardian): Has anyone named in this petition had any involvement with Arizona Department of Child Safety Yes No (DCS)? If "Yes", list DCS or Juvenile Court case # Case manager's name, phone number, and site code: 5. DOCUMENTS. The following documents are attached which support the statements made: A. B. C. D. E. � Superior Court of Arizona in Maricopa County - Juvenile Division ALL RIGHTS RESERVED Page 4 of 5 JVD11f 031616 Use current form American LegalNet, Inc. www.FormsWorkFlow.com Case No. RELIEF REQUESTED: Based on the information listed above, Petitioner requests: A. Because immediate action is required, that the children be made a temporary ward(s) of the Court committed to the care, custody, and control of the Arizona Department of Child Safety (DCS) with temporary physical custody to be placed in the Petitioner(s) who should be authorized to sign for medical treatment. The Arizona Department of Child Safety (DCS) may be authorized to consent for out-of-state travel within the United States for up to thirty days. A preliminary protective conference and, following that conference, a preliminary protective hearing on this Petition be set in front of a judicial officer. An initial dependency hearing on this Petition be set in front of a judicial officer. The parents be ordered to pay a reasonable sum to the Arizona Department of Child Safety (DCS) for the care, maintenance, and support of the children should the children be placed in a foster home or institutional care. That, after hearing this matter, the Court declare the children dependent and enter such orders for commitment, custody, care and support or such other relief for the children's welfare. B. C. D. E. DECLARATION UNDER PENALTY OF PERJURY I declare under penalty of perjury that the contents of this document or true and correct. Signature Date PRINTED NAME of Person who signed � Superior Court of Arizona in Maricopa County - Juvenile Division ALL RIGHTS RESERVED Page 5 of 5 JVD11f 031616 Use current form American LegalNet, Inc. www.FormsWorkFlow.com