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 Name of Minor whose birth record needs correction PETITION TO AMEND BIRTH CERTIFICATE OF A MINOR (A.R.S. � 36-337) UNDER PENALTY OF PERJURY 1. INFORMATION ABOUT THE PETITIONER (the person filing this request): MY FULL NAME IS: (First) Address is as listed at top left above, or if not, my address is: I am the Minor's: County of Residence: Place of Birth*: Mother (Middle) (Last) Father Legal Guardian Date of Birth*: (Month / Day/ Year) (City or County, State, Nation) * "Date" and "Place" of birth information not required for legal guardian. � Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED Page 1 of 4 CVABM11f - 050115 American LegalNet, Inc. www.FormsWorkFlow.com Case No.______________ 2. INFORMATION ABOUT THE MINOR WHOSE BIRTH RECORD NEEDS CORRECTION: MINOR'S NAME as it appears on the birth certificate: (First) (Middle) (Last) Address is same as Petitioner's, or if not, minor's complete address is: County of Residence: Date of Birth: (Month / Day/ Year) Place of Birth: (City, County) ARIZONA A CERTIFIED COPY OF THE MINOR'S CURRENT ARIZONA BIRTH CERTIFICATE IS ATTACHED. 3. INFORMATION ABOUT THE BIRTH RECORD: A. The birth record contains INCORRECT information about the MINOR CHILD: CHILD'S NAME DATE OF BIRTH PLACE OF BIRTH Other Information appears wrongly as appears wrongly as appears wrongly as appears wrongly as Following is the CORRECT information about the MINOR CHILD. I ask that the birth record be ordered changed as indicated below: CHILD'S NAME DATE OF BIRTH PLACE OF BIRTH Other Information should appear as should appear as should appear as should appear as � Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED Page 2 of 4 CVABM11f - 050115 American LegalNet, Inc. www.FormsWorkFlow.com Case No.______________ B. The birth record contains INCORRECT information about the FATHER: FATHER'S NAME* DATE OF BIRTH PLACE OF BIRTH RACE appears wrongly as appears wrongly as appears wrongly as appears wrongly as Following is the CORRECT information about the FATHER. I ask that the birth records be ordered changed as indicated below: FATHER'S NAME* DATE OF BIRTH PLACE OF BIRTH RACE should appear as should appear as should appear as 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* DATE OF BIRTH PLACE OF BIRTH RACE MARITAL STATUS appears wrongly as appears wrongly as appears wrongly as appears wrongly as 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* should appear as CVABM11f - 050115 Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com � Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED Case No.______________ DATE OF BIRTH PLACE OF BIRTH RACE MARITAL STATUS should appear as 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. UNDER OATH OR BY AFFIRMATION I swear or affirm under penalty of perjury that the contents of this document are true and correct to the best of my knowledge and belief. Date Signature Printed Name 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 Page 4 of 4 CVABM11f - 050115 American LegalNet, Inc. www.FormsWorkFlow.com