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: CV PETITION FOR COURT ORDER TO AMEND BIRTH CERTIFICATE of an ADULT Name of Adult whose birth record needs correction (A.R.S. § 36-337) UNDER PENALTY OF PERJURY 1. INFORMATION ABOUT THE ADULT whose birth record needs correction: FULL NAME: (First) (Last) Current Legal Name (if different from above) : (First) (Last) Address is as listed at top left above or if not, my address is: A CERTIFIED COPY OF MY CURRENT ARIZONA BIRTH CERTIFICATE IS ATTACHED. © Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED CVAB11f- 050115 Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case No._________________ 2. INFORMATION ON THE BIRTH RECORD A. The birth record contains INCORRECT information about the above-named adult: MY NAME appears wrongly as DATE OF BIRTH appears wrongly as PLACE OF BIRTH appears wrongly as Other Information appears wrongly as Following is the CORRECT information about the above-named adult: I ask that the birth record be ordered changed as indicated below: MY NAME should appear as DATE OF BIRTH should appear as PLACE OF BIRTH should appear as Other Information should appear as B. The birth record contains INCORRECT information about the FATHER. FATHER'S NAME* appears wrongly as DATE OF BIRTH appears wrongly as PLACE OF BIRTH appears wrongly as RACE appears wrongly as CVAB11f- 050115 Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com © Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED Case No._________________ Following is the CORRECT information about the FATHER. I ask that the birth records be ordered changed as indicated below: FATHER'S NAME* should appear as DATE OF BIRTH should appear as PLACE OF BIRTH should appear as RACE should appear as * to correct error in name of the father ­ not to change identity / paternity. C. The birth record contains INCORRECT information about the MOTHER. MOTHER'S NAME* appears wrongly as DATE OF BIRTH appears wrongly as PLACE OF BIRTH appears wrongly as RACE appears wrongly as MARITAL STATUS appears wrongly as RESIDENTIAL ADDRESS appears wrongly as Following is the CORRECT information about the MOTHER. I ask that the birth records be ordered changed as indicated below: MOTHER'S NAME* DATE OF BIRTH should appear as should appear as © Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED CVAB11f- 050115 Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case No._________________ PLACE OF BIRTH RACE MARITAL STATUS should appear as should appear as should appear as RESIDENTIAL ADDRESS should appear as * to correct error in name of the mother ­ not to change identity / maternity. REQUEST TO THE COURT: I request the Arizona Office of Vital Records be ordered to remove and replace the incorrect information on the subject birth record with the correct information as indicated above. OATH OR AFFIRMATION OF APPLICANT I affirm under penalty of perjury the information provided on this document is true and correct. Date: Petitioner's Signature Printed Name of Petitioner STATE OF COUNTY OF Subscribed and sworn to or affirmed before me this: (date) . by (notary seal) Deputy Clerk or Notary Public © Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED CVAB11f- 050115 Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com