FOR CLERK’S USE ONLY Name of Person Filing: _____________________________________________ Mailing Address: _____________________________________________ City, State, Zip Code: _____________________________________________ Day/Evening Phone Number: __________________________________________ ATLAS Number (if applicable) __________________________________________ Attorney Bar Number (if Applicable) _____________________________________ Self, Without a Lawyer OR Representing: Petitioner Respondent Attorney for: SUPERIOR COURT OF ARIZONA MOHAVE COUNTY Regarding the Matter of: Case Number:__________________________ ________________________________________ (Name of Petitioner) PETITION FOR LEGAL SEPARATION WITH MINOR CHILDREN AND ________________________________________ (Name of Respondent) GENERAL INFORMATION: 1. INFORMATION ABOUT ME, THE PETITIONER: Name: _____________________________________________________________________________ Address: _____________________________________________________________________________ Date of Birth: _____________________________________________________________________________ Occupation: _____________________________________________________________________________ I have lived in Arizona for __________ years and/or __________ months in a row. 2. INFORMATION ABOUT MY SPOUSE, THE RESPONDENT: Name: _____________________________________________________________________________ Address: _____________________________________________________________________________ Date of Birth: _____________________________________________________________________________ Occupation: _____________________________________________________________________________ He/she has lived in Arizona for __________ years and/or __________ months in a row. 3. INFORMATION ABOUT MY MARRIAGE: Date of Marriage;_____________________________ City and state, or country where we were married:__________________________________________________ 4. CHILDREN OF THE PARTIES WHO ARE LESS THAN 18 YEARS OLD (check one box): There are no children under the age of 18 either born to, or adopted by, the parties. NOTE: IF YOU CHECKED THIS BOX, STOP. YOU SHOULD BE USING THE PETITION PACKET TO GET A LEGAL SEPARATION WITHOUT CHILDREN. The following minor child(ren) are under age 18 and were born to or adopted by my spouse and me: (Attach extra pages if necessary). 9/20/2010 Page 1 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Case No._____________________________________ Child’s Name: _______________________________________________________________________ Birth date: _______________________________________________________________________ Address: _______________________________________________________________________ Length of Time at Address: ______________________________________________________________ Child’s Name: _______________________________________________________________________ Birthdate: _______________________________________________________________________ Address: _______________________________________________________________________ Length of Time at Address: ______________________________________________________________ Child’s Name: _______________________________________________________________________ Birthdate: _______________________________________________________________________ Address: _______________________________________________________________________ Length of Time at Address: ______________________________________________________________ Child’s Name: _______________________________________________________________________ Birthdate: _______________________________________________________________________ Address: _______________________________________________________________________ Length of Time at Address: ______________________________________________________________ 5. RESIDENCY REQUIREMENT: I OR my spouse live, or are stationed while a member of When I file this document with the court, either the Armed Forces, in Arizona. (WARNING: If this statement is not true, you cannot file for legal separation until it becomes true.) 6. DESIRE TO LIVE SEPARATE AND APART: My marriage is irretrievably broken (my marriage is over) or I and/or my spouse desire to live separate and apart. (This must be a true statement or you cannot file for a Petition for Legal Separation.) 7. DOMESTIC VIOLENCE: (If you intend to ask for joint custody, there must have been no “significant” domestic violence in your marriage. A.R.S. §25-403.03.) Check the box that makes a true statement: Significant domestic violence 8. has OR has not occurred during this marriage. PREGNANCY: Wife is not pregnant, OR Wife is pregnant The baby is due on _________________(date), (and, check one box below): The Petitioner and Respondent are the parents of the child, OR Petitioner is not the parent of the child, OR Respondent is not the parent of the child 9/20/2010 Page 2 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Case No.____________________________________ 9. SPOUSAL MAINTENANCE/SUPPORT (ALIMONY): Neither party is entitled to Spousal Maintenance/Support (alimony); OR Petitioner OR Respondent is entitled to Spousal Maintenance/Support because: (Check one or more of the box(es) below that apply. At least one reason must apply to get spousal maintenance/support.) Person lacks sufficient property to provide for his or her reasonable needs; Person is unable to support himself or herself through appropriate employment; Person is the custodian of minor child(ren) whose age or condition is such that the person should not be required to seek employment outside the home; Person lacks earning ability in the labor market adequate to support himself or herself; AND/OR Person contributed to the educational opportunities of the other spouse or had a marriage of long duration and is now of an age that precludes the possibility of gaining employment adequate to support himself or herself. INFORMATION ABOUT PROPERTY AND DEBTS 10. (a) PROPERTY ACQUIRED DURING THE MARRIAGE: (Check one box.) My spouse and I did not acquire community property during the marriage; OR My spouse and I acquired community property during our marriage, and we should divide it as follows: (List the property and the value of the property, and check the box to tell the court who should get the property.) WARNING: You must be specific. You must describe the property that should go to you and then check the box, and describe the property that should go to your spouse, and check the box. For example, under household furnishing you could say, blue and white living room sofa, and then check the box to say whether it should go to you or to your spouse. Never list an item and then check both the Petitioner box and the Respondent box. DESCRIPTION OF PROPERTY/ VALUE OF PROPERTY: You (Petitioner) Your Spouse (Respondent) Value Real estate at: _______________________ Legal Description: ____________________ ___________________________________ ___________________________________ $_______________ Real estate at: _______________________ Legal Description: ____________________ ___________________________________ ___________________________________ $_______________ Household furniture and appliances: ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 9/20/2010 $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ Page 3 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Case No.___________________________________ DESCRIPTION OF PROPERTY/ VALUE OF PROPERTY: (Continued) You (Petitioner) Your Spouse (Respondent) Value Household furnishings: ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ Other items: ___________________________________ ___________________________________ ___________________________________ ___________________________________ $_______________ $_______________ $_______________ $_______________ Pension/retirement fund/profit sharing/stock plan/401K: ___________________________________ ___________________________________ ___________________________________ $_______________ $_______________ $_______________ Motor Vehicles: Make _____________________________ Model _____________________________ Year__________ Vin _____________________________ Lien Holder __________________________ $_______________ Make _____________________________ Model _____________________________ Year__________ Vin _____________________________ Lien Holder __________________________ $_______________ 10. (b) PROPERTY ACQUIRED BEFORE THE MARRIAGE: (Check all boxes that apply.) I do not have any property that I brought into the marriage (separate property). My spouse, the Respondent does not have any property that he or she brought into the marriage (separate property). I have property that I brought into the marriage (separate property). I want this property awarded to me as described below. My spouse, the Respondent, has property that he or she brought into the marriage. I want this property awarded to my spouse as described below. Separate Property: (List the property and the value of the property, and check the box to tell the court who should get the property.) DESCRIPTION OF PROPERTY/ VALUE OF PROPERTY: ___________________________________ ___________________________________ 9/20/2010 You (Petitioner) Your Spouse (Respondent) Value $_________________ $_________________ Page 4 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Case No._____________________________________ (DESCRIPTION OF PROPERTY Continued) You (Petitioner) Your Spouse (Respondent) ___________________________________ ___________________________________ ___________________________________ ___________________________________ Value $_________________ $_________________ $_________________ $_________________ 11. (a) DEBTS INCURRED DURING THE MARRIAGE: (Check one box.) My spouse and I did not incur any community debts during the marriage, OR We should divide the responsibility for the community debts incurred during the marriage as follows: DESCRIPTION OF DEBT/ AMOUNT OF DEBT: ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ You (Petitioner) Your Spouse (Respondent) Value $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ 11. (b) SEPARATE DEBTS: (Check all boxes that apply.) My spouse and I do not have any debts that were incurred prior to the marriage, OR I have separate debt that I incurred prior to the marriage which should be paid by me as described below: My spouse has separate debt that he or she incurred prior to the marriage which should be paid by my spouse as described below: DESCRIPTION OF DEBT/ AMOUNT OF DEBT: ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ You (Petitioner) Your Spouse (Respondent) Value $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ 12. TAX RETURNS: After the Judge or Commissioner signs the Order of Legal Separation, the parties will file state and federal taxes as follows: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 13. WRITTEN CUSTODY AGREEMENT: (Check only if true.) My spouse and I have a written agreement signed by both of us about the maintenance of a spouse, division of property/debt, custody, parenting time, and child support for our minor child(ren), and I have attached a copy of the written agreement. 9/20/2010 Page 5 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Case No.____________________________________ OTHER STATEMENTS TO THE COURT UNDER OATH: You must tell the court the truth. Lying to the court is a crime and the court can punish you for lying. To file for legal separation, you must be able to tell the court that the following statements are true. Check the box in front of each statement if the statement is true. If you do not understand what the statement means, read the instructions that go along with the Petition for Legal Separation OR seek legal advice. 14. TRUE The conciliation requirements under Arizona law either do not apply or have been met. 15. TRUE This court has jurisdiction to decide child custody matters under Arizona law REQUESTS TO THE COURT: A. LEGAL SEPARATION: An order of legal separation. Order spousal maintenance/support to be paid by Petitioner, or Respondent in the amount of ____________________ per month, and the statutory fee, beginning with the first day of the month after the Judge or Commissioner signs the Legal Separation and continuing until the person receiving the spousal maintenance/support is remarried or deceased, or for _________________ months. These payments, and a fee for handling, will be paid through the Support Payment Clearinghouse. B. C. COMMUNITY PROPERTY: Make a fair division of all community property as requested in this Petition. D. COMMUNITY DEBTS: Order each party to pay community debts as requested in the Petition, and to pay any other community debts unknown to the other party. Order each party to pay and hold the other party harmless from debts incurred by him or her since the parties separation on (date): _________________. E. SEPARATE PROPERTY AND DEBTS: Award each party his or her separate property and debt. F. CHILD CUSTODY AND PARENTING TIME: Award custody and parenting time of the children common to the parties, and less than 18 years as follows: (Check either the sole custody box or the joint custody box. If you check the sole custody box, check only one box related to parenting time.) F.1. SOLE CUSTODY. Mother is awarded the sole custody of _____________________________ and/or Father is awarded the sole custody of __________________________ subject to parenting time as follows Reasonable parenting time rights to the parent, who does not have custody, as will be described in the Parenting Plan attached to the Order of Legal Separation. Reasonable parenting time rights to the parent who does not have custody pursuant to the the Mohave County Parent Access/Parenting time Guidelines. Supervised parenting time between the children and the Mother OR Father is in the best interest of the children because: (Explain the reasons for supervision or no parenting time. Use extra paper if necessary.) a. Name of the person who will supervise: _____________________________________________ b. Requested restrictions on parenting time: (explain here) ________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 9/20/2010 Page 6 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Case No._____________________________________ c. the parent being The cost of supervised parent/child parenting time will be paid by the parent having custody; shared equally by the parties. supervised; No parenting time rights to the parent who does not have custody is in the best interests of the child(ren) because: (Explain the reasons for no parenting time. Use extra paper if necessary): ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ F.2. JOINT CUSTODY: Mother and Father agree to act as joint custodians of the minor child(ren) as set forth in the Parenting Plan signed by the parties, if the court agrees with the Parenting Plan. (For joint custody, there must have been no ‘significant” domestic violence. A.R.S. §25-403.03) G. CHILD SUPPORT: Order that child support will be paid by: H. MEDICAL, DENTAL, VISION CARE FOR MINOR CHILDREN: Order that Mother, OR Father in a reasonable amount as determined by the court under the Arizona Child Support Guidelines. (I will attach the Child Support Order to the Decree.) Support payments will begin on the first day of the first month following the entry of the decree. These payments, and a fee for handling, will be paid through the Support Payment Clearinghouse and collected by automatic wage assignment. Petitioner is responsible for providing: medical dental vision care insurance Respondent is responsible for providing: medical dental vision care insurance Mother and Father will pay for all reasonable unreimbursed medical, dental, and health-related expenses incurred for the child(ren) in proportion to their respective incomes as described in the Parents’ Worksheet, which I will submit with the Decree. I. TAX EXEMPTION: The parties will claim the children as income tax dependency exemptions on federal and state income tax returns as follows: Parent entitled to claim Mother Mother Mother Mother J. Father Father Father Father Name of child __________________________ __________________________ __________________________ __________________________ Current tax year Later tax years ________________ ________________ ________________ ________________ ______________ ______________ ______________ ______________ OTHER ORDERS I AM REQUESTING (Explain request here): __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 9/20/2010 Page 7 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Case No._____________________________________ OATH OR AFFIRMATION AND VERIFICATION STATE OF ARIZONA County of Mohave ) ) ss. ) I declare under penalty of perjury that the information I have provided is true and correct to the best of my knowledge and belief. SIGNATURE: ___________________________________________ DATE: ________________________________ Sworn to or affirmed before me this ____________ day of _____________,______ by ____________________________________________. My Commission Expires:___________________________ 9/20/2010 ______________________________________ Notary Public / Deputy Clerk Page 8 of 8 American LegalNet, Inc. www.FormsWorkFlow.com