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: Attorney for: Petitioner Respondent SUPERIOR COURT OF ARIZONA MOHAVE COUNTY Regarding the Matter of: Case Number:__________________________ ________________________________________ (Name of Petitioner) PETITION FOR PATERNITY (Check one box only) AND CHILD CUSTODY, PARENTING TIME, and CHILD SUPPORT ________________________________________ (Name of Respondent) CHILD CUSTODY, PARENTING TIME ONLY GENERAL INFORMATION: 1. INFORMATION ABOUT THE PETITIONER Name: _____________________________________________________________________________ Address: _____________________________________________________________________________ County of residence: _________________________________________________________________________ Date of Birth: _____________________________________________________________________________ Occupation: _____________________________________________________________________________ Relationship to minor child(ren) for whom I want the paternity order: Mother I claim to be the Father I am a court-appointed guardian, conservator or “best friend” for the minor child(ren) born out of wedlock 2. INFORMATION ABOUT THE RESPONDENT Name: _____________________________________________________________________________ Address: _____________________________________________________________________________ County of residence: _________________________________________________________________________ Date of Birth: _____________________________________________________________________________ Occupation: _____________________________________________________________________________ Relationship to minor child(ren) for whom I want the CUSTODY/PARENTING TIME ORDER: Mother Father Other: (explain) ________________________________________________________________ Revised 4/21/2010 Page 1 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Case No.___________________________________ 3. JURISDICTION: WHY I AM FILING THIS COURT CASE IN ARIZONA AGAINST THE OTHER PERSON: (check all that apply) The person is a resident of Arizona I believe that I will personally serve the person in Arizona (see packet on service to know about this) The person agrees to have the case heard here and will file written papers in the court case; The person lived with the minor child(ren) in this state at some time; The person lived in this state and provided pre-birth expenses or support for the minor child(ren); The minor child(ren) live/lives in this state as a result of the acts or directions of the person; The person had sexual intercourse in this state as a result of which the minor child(ren) may have been conceived; The person signed a birth certificate that is filed in this state; The person did any other acts that substantially connect the person with this state (see a lawyer to help you determine this). 4. INFORMATION ABOUT MINOR CHILD(REN) FOR WHOM I WANT PATERNITY ORDER: Name: _____________________________________ Birthdate: (month/day/year)______________________ City, State, Nation of Birth: ______________________ ____________________________________________ Name: _____________________________________ Birthdate: (month/day/year)______________________ City, State, Nation of Birth: ______________________ ____________________________________________ Name: _____________________________________ Birthdate: (month/day/year) ______________________ City, State, Nation of Birth: ______________________ ____________________________________________ Name: _____________________________________ Birthdate: (month/day/year)______________________ City, State, Nation of Birth: ______________________ ____________________________________________ Name: _____________________________________ Birthdate: (month/day/year) ______________________ City, State, Nation of Birth: ______________________ ____________________________________________ Name: _____________________________________ Birthdate: (month/day/year)______________________ City, State, Nation of Birth: ______________________ ____________________________________________ STATEMENTS ABOUT PATERNITY: 5. WHY YOU THINK THE PERSON IS THE FATHER OF THE MINOR CHILD(REN): (check which box applies). AFFIDAVIT: Petitioner and Respondent signed an Affidavit of Paternity acknowledging that Petitioner or Respondent is the minor child(ren)’s natural father. A copy is attached. BIRTH CERTIFICATE: Petitioner or Respondent is named as the natural father on each of the minor child(ren)’s birth certificate(s). Copy (or copies) attached. BLOOD TEST: DNA Testing indicates: Petitioner or Respondent is the minor child(ren)’s natural father. Report(s) of test results attached. PARTIES LIVING TOGETHER: Petitioner and Respondent were not married to each other at any time during the ten months before birth of the minor child(ren). However, the parties lived together during the period(s) when the minor child(ren) could have been conceived. Revised 4/21/2010 Page 2 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Case No.________________________________ SEXUAL INTERCOURSE: Petitioner and Respondent were not living together but had sexual intercourse at the probable date(s) of conception of the minor child(ren). The mother of the minor child(ren) did not have sexual intercourse with anyone else during the periods in which the minor child(ren) could have been conceived. OTHER: (explain)_________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 6. ABOUT MARRIAGE AND HUSBAND (if applicable, check one box.) Mother was not married at the time minor child(ren) were born or conceived or at least 10 months before minor child(ren) were born or conceived, OR Mother was married when minor child(ren) were born or conceived or at least 10 months before minor child(ren) were born or conceived, but husband is not father of minor child(ren). Husband is a party to this court case because of marriage. OTHER INFORMATION ABOUT THE MINOR CHILD(REN): 7. WHERE THE CHILD(REN) WHO IS/ARE UNDER 18 YEARS OLD HAS/HAVE LIVED FOR THE LAST 5 YEARS. (Attach extra pages if necessary.) Child's Name _______________________________ Lived with __________________________________ Street address ______________________________ Child's Name _______________________________ Lived with __________________________________ Street address ______________________________ Dates: From ______________ To _________________ Relationship to child: ____________________________ City, State:____________________________________ Child's Name _______________________________ Lived with __________________________________ Street address ______________________________ 8. Dates: From ______________ To _________________ Relationship to child: ____________________________ City, State:____________________________________ Dates: From ______________ To _________________ Relationship to child: ____________________________ City, State:____________________________________ COURT CASES NOT INVOLVING CUSTODY OR PARENTING TIME RELATED TO THE CHILD(REN) UNDER 18 YEARS OLD: (check one box) I have or I have not been a party or a witness in court in this state or any other state regarding issues OTHER THAN the custody or parenting time of any minor child(ren) named above (If so, explain below, using extra pages if necessary. IF NOT, GO ON.) Name of each child: _________________________________________________________________________ Court state: _____________________________ Court location _______________________________________ Court case number _______________________ Current status _______________________________________ How the child(ren) is (are) involved: _____________________________________________________________ __________________________________________________________________________________________ Summary of any Court Order: __________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Revised 4/21/2010 Page 3 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Case No.__________________________________ 9. CUSTODY OR PARENTING TIME CASES RELATED TO CHILDREN UNDER 18 YEARS OLD: (check one box) I DO NOT HAVE I DO HAVE information about a custody or parenting time court case relating to any of the minor children named above that is pending in this state or in any other state (If so, explain below, using extra pages if necessary. IF NOT, GO ON). Name of each child: _________________________________________________________________________ Court state: _____________________________ Court location _______________________________________ Court case number _______________________ Current status _______________________________________ Nature of the Court proceeding: ________________________________________________________________ Summary of any Court Order: __________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 10. CUSTODY OR VISITATION CLAIMS OF ANY PERSON: (check one box) I DO NOT KNOW I DO KNOW a person other than the Petitioner or the Respondent who has physical custody or who claims custody or parenting time rights to any of the minor children named above. (If so, explain below, using extra pages if necessary. IF NOT, GO ON). Name of each child: __________________________________________________________________________ Name of person with the claim: _________________________________________________________________ Address of person with the claim: _______________________________________________________________ Nature of the claim: __________________________________________________________________________ 11. CUSTODY OF THE MINOR CHILD(REN): (If applicable, court must make findings in contested custody cases.) Sole Custody to Petitioner or Respondent or Joint Custody is in the best interests of the minor child(ren) for the following reasons: _______________ __________________________________________________________________________________________ __________________________________________________________________________________________ OTHER STATEMENTS TO THE COURT: 12. MEDICAL EXPENSES: There are OR There are no unreimbursed medical expenses incurred by the mother, resulting from the birth of the minor child(ren). If there are, these costs and expenses should be awarded to Petitioner or Respondent according to law. 13. OTHER EXPENSES: The parties should be ordered to divide between them any uninsured medical, dental, or health expenses, reasonably incurred for the minor child(ren), in proportion to their respective incomes. 14. DOMESTIC VIOLENCE: (check if you are asking for joint custody.) Domestic violence has not occurred between the parties. Domestic Violence has occurred but it has not been significant. Explain why joint custody is still in the best interest of the minor child(ren) even though domestic violence has occurred. 15. VENUE: (Check here if the following statement is true): This is the proper Court to bring this lawsuit under Arizona law because it is the county of residence of the Petitioner, or the Respondent, or the minor child(ren). 16. DRUG CONVICTION WITHIN LAST TWELVE MONTHS: (Check one box.) I have not been convicted for a drug offense or driving under the influence of drugs or alcohol in the last twelve (12) months, OR Revised 4/21/2010 Page 4 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Case No.___________________________________ I have been convicted for a drug offense or driving under the influence of drugs or alcohol in the last twelve (12) months. However, the parenting time arrangement I am requesting appropriately protects the minor child(ren). Explain how this arrangement appropriately protects the minor children. ____________ __________________________________________________________________________________________ __________________________________________________________________________________________ REQUESTS I MAKE TO THE COURT: 17. PATERNITY: Order that _________________________________________________ (legal name of the father, as on his birth certificate) be declared the natural father of the minor child(ren). 18. BIRTH CERTIFICATE: Order that the name of the father __________________________________ be added to each minor child’s birth certificate; (father’s name) 19. CHILD(REN) LAST NAME: (check the box and fill in the blank if you want this): Order that each minor child’s last name be changed to the last name of __________________________; 20. CUSTODY OF MINOR CHILD(REN) AND PARENTING TIME: (check and complete 1 or 2); A. SOLE CUSTODY: Sole custody of the minor child(ren) awarded to Parenting Time as follows: 1.) Petitioner or Respondent subject to Reasonable Parenting Time rights to the parent not having custody, as will be described in a Parenting Plan attached to the Final Order, OR 2.) Supervised parenting time between the minor child(ren) and Petitioner or Respondent is in the best interests of the minor child(ren) for the following reasons: (explain here reasons for supervision or no parenting time): _______________________ ____________________________________________________________________________________ ____________________________________________________________________________________ i. Supervised parent/child access to the parent not having custody, only in the presence of another person, who is named by the court (suggestion below) upon a finding that supervised access is in the best interest of the minor child(ren), • Person to supervise: _______________________________________________ • Requested restrictions on Parenting Time: (explain here) ________________________________________________________________ ________________________________________________________________ • The cost of supervised parenting time shall be paid by the parent being supervised; the parent having custody; shared equally by the parties. OR ii. No parenting time rights to the parent not having custody. OR B. JOINT CUSTODY: Petitioner and Respondent agree to act as joint custodians of the minor child(ren), as set forth in the Parenting Plan by the parties, signed by both parties, if the court adopts the agreed terms of Revised 4/21/2010 Page 5 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Case No._________________________________ the joint custody agreement setting forth the custody and parenting time agreement between the parties. There have been no significant acts of domestic violence by either parent. 21. CHILD SUPPORT: Order that child support shall be paid by: (check one box) Petitioner or Respondent in a reasonable amount as determined by the court under the Arizona Child Support Guidelines. Support payments shall begin on the first day of the first month following the entry of the Paternity Decree/Order. These payments, plus a statutory fee for handling, shall be paid through the Support Payment Clearinghouse and collected by automatic wage assignment. Further, that costs for past child support and care for child(ren) in the amount of $_______________ shall be paid by Petitioner or Respondent in the amount of $_______________ each month until paid in full. Payments shall be made as stated above. 22. EXPENSES OF MOTHER: Order that Petitioner or Respondent pay a reasonable amount to cover unreimbursed expenses incurred by the mother related to the birth of each child(ren). 23. HEALTH, MEDICAL, DENTAL, VISION CARE INSURANCE AND HEALTH CARE EXPENSES FOR CHILDREN UNDER THE AGE OF 18: Petitioner should provide: medical dental vision care insurance Respondent should provide: medical dental vision care insurance Order that Petitioner and Respondent pay for all reasonable unreimbursed medical, dental, vision care, and health-related expenses incurred for the minor child(ren) in proportion to their respective incomes as described on the Parents’ Worksheet, which shall be submitted with the Judgment and Order. 24. TESTING AND COSTS: Order that if paternity is contested, Petitioner and Respondent be ordered to submit to such blood and tissue tests as may be necessary by this Court to establish paternity, and that Respondent must pay all costs and expenses of this lawsuit, if he/she contests these proceedings, including the costs of the blood tests or other genetic testing; filing each child’s birth certificate; attorneys’ fees and court costs; 25. OTHER ORDERS I AM REQUESTING (explain request here): __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ OATH OR AFFIRMATION 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:___________________________ Revised 4/21/2010 ______________________________________ Notary Public / Deputy Clerk Page 6 of 6 American LegalNet, Inc. www.FormsWorkFlow.com