Person Filing: Mailing Address: City, State, Zip: Day/Evening Phone: Person Filing is: If Attorney: Name: Attorney Bar No. / SELF (No Attorney) OR Attorney Atty Phone: FOR CLERK'S USE ONLY SUPERIOR COURT OF ARIZONA IN MARICOPA COUNTY JUVENILE COURT In the Matter of the Emancipation of: Case Number JE: PETITION FOR EMANCIPATION OF A MINOR A.R.S. § 12-2451 A Minor STATEMENTS TO THE COURT UNDER OATH OR BY AFFIRMATION • I am at least 16 years old. • I am a resident of Arizona and of the county where I am filing this request. • I am financially self-sufficient; I am able to support myself and provide for my own food, housing, and medical care. • I have read and understand the information provided by the Court that explains the rights and obligations of an emancipated minor and the potential risks and consequences of emancipation. • I am not a ward of the court: I am not on probation or parole, or in the care or custody of CPS or other state agency, and no final order of “Dependency” has been entered. 1. PERSONAL INFORMATION ABOUT ME, “THE MINOR”, REQUESTING EMANCIPATION: My Name: First Middle Last Mailing Address: City, State, Zip Code: Day/Evening Telephone: ( ) / ( ) Date of Birth: (Month) © Superior Court of Arizona in Maricopa County July 11, 2007 ALL RIGHTS RESERVED (Day Page 1 of 6 (Year) JE12f Use only most current version American LegalNet, Inc. www.FormsWorkFlow.com Case Number JE: 2. PERSONS ENTITLED TO NOTICE of this matter as required by the Court and under Arizona law, A.R.S. 12-2451. If applicable, check the box for “Parental Rights Terminated by Court Order” or “Deceased.” If “Deceased”, attach proof such as death certificate or obituary notice. MOTHER Name: Deceased Parental Rights Terminated by Court Order Mailing Address: City, State, Zip Code: Day/Evening Telephone: FATHER ( ) /( ) Name: Deceased Parental Rights Terminated by Court Order Mailing Address: City, State, Zip Code: Day/Evening Telephone ( ) /( ) LEGAL GUARDIAN Name: Deceased Mailing Address: City, State, Zip Code: Day/Evening Telephone ( ) /( ) LEGAL GUARDIAN Name: Deceased Mailing Address: City, State, Zip Code: Day/Evening Telephone 3. ( ) /( ) I CURRENTLY HAVE ONE OR MORE LEGAL GUARDIANS BECAUSE: Explain what happened to cause someone to request be appointed your guardian or the reasons or circumstances that caused the Court to appoint your guardian(s). FACTS TO SUPPORT MY REQUEST FOR EMANCIPATION: The following answers and statements explain how I will handle my financial, personal, and social affairs, provide for my own food, housing and medical care, maintain my educational or vocational training and my employment situation. © Superior Court of Arizona in Maricopa County July 11, 2007 ALL RIGHTS RESERVED Page 2 of 6 JE12f Use only most current version American LegalNet, Inc. www.FormsWorkFlow.com Case Number JE: 4. My Street Address City, State, Zip Code I have been living there since: (month/date/year) 5. I live there with (name and relationship of all persons, including children): 6. a. b. I attend (name of school)______________________________ and I am in the ______ grade. I am NOT in school. The highest grade of education I have completed is ______ grade. c. My plans concerning education or job training are as follows: 7. a. I am not receiving public assistance or TANF and I do not intend to apply for either. b. I am receiving public assistance or TANF. The monthly amount received is: c. I have applied for or intend to apply for public assistance or TANF. 8. a. I am currently employed by: (List name, address, and contact phone number for employers.) Employer # 1 (Attach pay stub) Employer # 2 (Attach pay stub) Job Title: Job Title: I started work: for Employer #1: (month/year) b. $ Employer #2: I am NOT currently employed. I last worked from: (starting month, year) To: (ending month and year) My gross monthly earnings (before taxes or other deductions) were: © Superior Court of Arizona in Maricopa County July 11, 2007 ALL RIGHTS RESERVED Page 3 of 6 $ JE12f Use only most current version American LegalNet, Inc. www.FormsWorkFlow.com Case Number JE: Amount 9. My average gross monthly income (annual amount divided by 12) is shown below. a. Salary / Wages, including bonuses and overtime, before taxes or other deductions $ b. Money received from others (list name, your relationship to those persons and amounts (below)) Name, Relation: $ Name, Relation: $ c. Social Security Survivor Benefits (received due to death of a parent) $ d. Social Security Disability Benefits $ e. Child Support Received for MY child(ren) $ f. Other source of income (specify source) $ TOTAL MONTHLY INCOME: g. (Add 9 a-f) $ Value 10. I have the following assets (things of value that I own): a. Cash $ b. Checking Account(s) (total, if more than one) $ c. Savings Account(s) $ (total, if more than one) d. Stocks, Bonds e. Trust Fund(s) $ (total, if more than one) $ f. Vehicle (Year, Make, and Model) $ g. Other (specify) $ h. (Add 10 a-g) TOTAL VALUE OF ASSETS: $ Amount 11. I have the following monthly expenses: a. Housing $ b. Food (groceries plus dining out) $ c. Clothing $ d. Utilities (phone plus electric, gas, cellular, water & sewer) $ 1. (insurance) $ 2. (doctor, dentist, hospital, urgent care) $ 3. (prescription medications) Medical $ e. Total Medical Expenses f. Transportation (add 1-3, carry to right column) (public transit, bus and taxi) © Superior Court of Arizona in Maricopa County July 11, 2007 ALL RIGHTS RESERVED Page 4 of 6 $ $ JE12f Use only most current version American LegalNet, Inc. www.FormsWorkFlow.com Case No. JE _________________________ 1. (monthly payments) $ 2. (insurance) $ 3. (fuel/gasoline) $ 4. (service, maintenance and repair) Vehicle $ g. Total Vehicle Expenses (add 1-4, carry to right column) $ h. Child Support Paid for my children (Amount I pay to someone else) $ i. Other (specify) $ j. TOTAL MONTHLY EXPENSES: 12. I will provide for my health care through (Add 11 a-i) insurance through employer AHCCS $ Other If “Other”, explain: 13. At least one of the following is included with this request: (At least one box must be checked; you may check and attach more than one to further support your request. Attached is documentation that I have been living on my own for at least three consecutive months Attached is a statement explaining why I believe the home of my parent(s) or legal guardian(s) is NOT a healthy or safe environment: Attached is a notarized statement by one or more of my parent(s) and/or legal guardian(s) that contains written consent to my emancipation and explanation. 14. I am aware that the Court may refer me and any parent or guardian to mediation. (optional) I believe mediation is not appropriate because of family violence or: © Superior Court of Arizona in Maricopa County July 11, 2007 ALL RIGHTS RESERVED Page 5 of 6 JE12f Use only most current version American LegalNet, Inc. www.FormsWorkFlow.com Case No. JE _________________________ REQUESTS TO THE COURT 5. I REQUEST THE COURT ENTER AN ORDER FOR MY EMANCIPATION. OATH OR AFFIRMATION OF MINOR PETITIONING FOR EMANCIPATION I swear or affirm that I have read this document and that the contents are true and correct to the best of my knowledge, information, and belief, under penalty of law. Signature of Minor Month/Date/Year Signed and sworn to or affirmed before me this date: Michael K. Jeanes, Clerk of Superior Court Notary OR By: My Commission Expires: © Superior Court of Arizona in Maricopa County July 11, 2007 ALL RIGHTS RESERVED Deputy Clerk Page 6 of 6 JE12f Use only most current version American LegalNet, Inc. www.FormsWorkFlow.com