For Clerk's Use Only Name of Person Filing: ___________________________________ Mailing Address: ___________________________________ City, State, and Zip Code: ___________________________________ Phone Number(s): ___________________________________ ATLAS Number (if applicable):___________________________________ State Bar Number (if applicable):_________________________________ Representing: Self (Without Attorney) or Attorney for: Petitioner Respondent SUPERIOR COURT OF ARIZONA MOHAVE COUNTY Case Number: ________________________ (Name of Petitioner) AND AFFIDAVIT REGARDING MINOR CHILDREN (Name of Respondent) NOTICE: This "Affidavit Regarding Minor Children" is required for all legal decision making cases. You must fill out this Affidavit completely, and provide accurate information. Use additional paper if necessary. You must give copies of this Affidavit and all other required documents to the other party, and to the judge. 1. CHILDREN OF THE PARTIES WHO ARE UNDER 18 YEARS OLD. The following child(ren) are under age 18 and were born to, or adopted by, me and the other party. Name Birthdate: Name Birthdate: Name Birthdate: Name Birthdate: Age: Age: Age: Age: 2. INFORMATION REGARDING WHERE THE CHILDREN UNDER 18 YEARS OLD HAVE LIVED FOR THE LAST 5 YEARS. Child's Name: Address: City, State: Child's Name: Address: City, State: Child's Name: Address: City, State: Dates: From Lived with: Relationship to Child: Dates: From Lived with: Relationship to Child: Dates: From Lived with: Relationship to Child: To To To 3. COURT CASES IN WHICH I HAVE BEEN A PARTY/WITNESS THAT INVOLVED THE LEGAL DECISION MAKING / PARENTING TIME OF THE CHILD(REN). (Check one box.) I have or have not been a party/witness in court in this state or in any other state that involved the legal decision making / parenting time of the child(ren) named above. (If so, explain on separate paper. If not, go on.) Revised: 1/1/2013 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Case No.__________________________ Name of each child: Name of Court: Court Case Number: How the child is involved: Summary of any Court Order: Court Location: Current Status: 4. INFORMATION REGARDING PENDING COURT CASES RELATED TO THE LEGAL DECISION MAKING OF THE CHILD(REN). (Check one box.) I do have or I do not have information about a legal decision making /parenting time court case relating to any of the children named above that is pending in this state or in any other state. (If so, explain. If not, go on.) Name of each child: Name of Court: Court Case Number: How the child is involved: Summary of any Court Order: Court Location: Current Status: 5. LEGAL DECISION MAKING OR PARENTING TIME CLAIMS OF ANY PERSON. (Check one box.) I do know or I do not know a person other than the Petitioner or the Respondent who has physical legal decision making or who claims legal decision making or parenting time rights to any of the children named in this Affidavit. (If so, explain below. If not, go on.) Name of each child: Name of person with the claim: Address of person with the claim: Nature of the claim: OATH OR AFFIRMATION AND VERIFICATION State of Arizona Mohave County ) ) ss. I swear or affirm that the information on this document is true and correct under penalty of perjury. _________________________________________ SIGNATURE ______________________________ DATE Sworn to or Affirmed before me this ______________ day of ______________________, 20_________ by _________________________________________ My Commission Expires: _______________________ ____________________________________ Deputy Clerk or Notary Public Revised: 1/1/2013 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com