For Clerk's Use Only Name of Person Filing: ________________________________________ Mailing Address: ________________________________________ City, State, and Zip Code: ________________________________________ Daytime Phone Number: ________________________________________ Evening Phone Number: ________________________________________ ATLAS Number (if applicable):________________________________________ State Bar Number (if applicable):______________________________________ Self Representing: Petitioner Respondent SUPERIOR COURT OF ARIZONA MOHAVE COUNTY _______________________________________ (Name of Petitioner/Plaintiff) Case Number: ________________________ _____________________________________ (Title of Form) AND _______________________________________ (Name of Respondent/Defendant) COMES NOW ______________________________ in the above captioned case to request the Court to: (Name) _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ For the following reason(s): _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ 10/9/2009 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Case No._____________________________ OATH OR AFFIRMATION STATE OF ARIZONA County of Mohave ) ) ss. ) I declare under penalty of perjury that the information on this form is true and correct to the best of my knowledge and belief. ___________________________________________ Signature ______________________________ Date Subscribed and sworn to (or affirmed) before me on this ______________day of ______________, 20_____. By:________________________________________ My commission Expires:_______________________ _____________________________________ Deputy Clerk / Notary Public Copy sent to: ____________________________________________ (other party) ____________________________________________ (address) ____________________________________________ (city, state, zip) on:_________________________________________ (date) 10/9/2009 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com