Name of Person Filing: _____________________________________________ Mailing Address: _____________________________________________ City, State, Zip Code: _____________________________________________ Day/Evening Phone Number: __________________________________________ FOR CLERK’S USE ONLY SUPERIOR COURT OF ARIZONA MOHAVE COUNTY Regarding the Matter of: Case Number:______________________________ ___________________________________________ ___________________________________________ Name of Child(ren) under the age of 18 years ___________________________________________ Petitioner(s) EMERGENCY PETITION FOR TEMPORARY CUSTODY ORDER WITHOUT NOTICE; TEMPORARY and PERMANENT CUSTODY and SUPPORT ________________________________ Respondent(s) COMES NOW, Petitioner, ____________________________________ pursuant to A.R.S. 25-415 and 25-501, and hereby petitions the Court for an order granting Petitioner custody of and support for the minor child(ren). The Petition is based upon the following: 1. This Court has jurisdiction over these proceedings pursuant to A.R.S. 25-415 et seq and 25502. Mohave County is both the permanent residence of the minor child(ren) and where the minor child(ren) can be found. 2. Petitioner, the (relationship to minor child(ren)) _____________________________, stands in loco parentis to the minor child(ren). The minor child(ren) has/have treated Petitioner as a parent, and Petitioner has formed a meaningful parental relationship with the minor child(ren) for a substantial period of time. 3. Petitioner, as ________________________________, has standing to file for custody in this One of the legal parents is deceased, matter because (check one) The minor child(ren)’s legal parents are not married to each other The parents have filed for dissolution of their marriage. 4. Mother’s name: ______________________________________________________ Why Mother is unable to provide care and custody for the minor child(ren): _____________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Page 1 of 3 9/23/2010 American LegalNet, Inc. www.FormsWorkFlow.com Case No._______________________________________ 5. Father’s name: ______________________________________________________ Why Father is unable to provide care and custody for the minor child(ren): _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 6. It would be significantly detrimental to minor child(ren) to be placed with either parent because: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 7. A court of competent jurisdiction has not entered or approved an order concerning the minor child(ren)’s custody within one year before filing of this Petition. 8. The following minor child(ren) listed below is/are the subject(s) of this action: __________________________________ Name of Child _________________ Date of Birth __________________________________ Name of Child __________________ Date of Birth __________________________________ Name of Child ___________________ Date of Birth __________________________________ Name of Child ____________________ Date of Birth 9. I have attached an Affidavit Regarding Minor Child(ren) to this petition. 10. I do not have any information of any custody proceedings concerning the minor child(ren) mentioned above and have not participated as a party, witness, or in any capacity in any other litigation concerning custody of minor child(ren) mentioned above; I do not know of any person not a party to this proceeding, who has physical custody or claims to have custody or visitation rights with any minor child(ren) mentioned above, in this or any other state. 11. Petitioner further alleges the following specific facts as follows: _______________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Page 2 of 3 9/23/2010 American LegalNet, Inc. www.FormsWorkFlow.com Case No.______________________________________ WHEREFORE, Petitioner respectfully requests that the Court enter the following orders: 1. Award sole custody of the minor child(ren), _____________________________ to Petitioner. 2. Order the following child support to be paid by mother/father: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ DATED this ___________day of ____________________, 20______ ______________________________________ Petitioner in Pro Per VERIFICATION STATE OF ARIZONA ) ) ss: County of Mohave ) COMES NOW, ___________________________________, after having first been duly sworn, hereby states that she/he is the Petitioner named in the foregoing Petition for Custody and Support; that she/he has read the same and knows the contents thereof, and that the statements set forth therein are true and correct to the best of her/his knowledge, information and belief, except as to those facts alleged upon information and belief, and as to those facts she/he believes them to be true. DATED this ______________day of ________________________, 20________. ___________________________________ Petitioner SUBSCRIBED AND SWORN to before me this _________day of _____________________, 20______, By, _________________________________________________________. My Commission Expires: ___________________ __________________________________________ Notary Public or Deputy Clerk Page 3 of 3 9/23/2010 American LegalNet, Inc. www.FormsWorkFlow.com