FOR CLERK’S USE ONLY Name of Person Filing: _____________________________________________ Mailing Address: _____________________________________________ City, State, Zip Code: _____________________________________________ Daytime Phone Number: _____________________________________________ Evening Phone Number: _____________________________________________ ATLAS Number (if applicable)__________________________________________ Attorney Bar Number (if Applicable)_____________________________________ Self Representing: Petitioner Respondent SUPERIOR COURT OF ARIZONA MOHAVE COUNTY Regarding the Matter of: Case Number:__________________________ ________________________________________ (Name of Petitioner) PETITION TO ESTABLISH (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 CUSTODY/PARENTING TIME ORDER: Mother Father Other: (explain) ________________________________________________________________ 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 11/13/09 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 CUSTODY/PARENTING TIME ORDER: Name:______________________________________ Birthdate:____________________________________ Current Address: _____________________________ ___________________________________________ County of residence: __________________________ Father: _____________________________________ Mother _____________________________________ Name: _______________________________________ Birthdate: _____________________________________ Current Address: _______________________________ _____________________________________________ County of residence: ____________________________ Father _______________________________________ Mother:_______________________________________ Name:______________________________________ Birthdate:____________________________________ Current Address: _____________________________ ___________________________________________ County of residence: __________________________ Father: _____________________________________ Mother _____________________________________ Name: _______________________________________ Birthdate: _____________________________________ Current Address: _______________________________ _____________________________________________ County of residence: ____________________________ Father _______________________________________ Mother:_______________________________________ STATEMENTS ABOUT PATERNITY AND CHILD SUPPORT: 5. PATERNITY WAS ESTABLISHED BY: (check one box). (A copy of any Order or document referenced here should already be in the court file or attached.) A Court Order for Paternity from this county or previously transferred to this county stating that ____________________________________ is the natural father of the minor child(ren). (A.R.S. § 25502(c)) Both parents signing an Acknowledgment of Paternity through the Hospital Paternity Program or other means provided by law after July 18, 1996, and a birth certificate listing the name of the father was issued as a result. We do not have an Order of Paternity, but we do have a Child Support Order. Parties were legally married when the minor child(ren) was (were) born, conceived or adopted.* *NOTE: If married when minor child(ren) born, conceived or adopted, and no Decree of Divorce or Separation has been issued, STOP! Do not use these forms unless advised to do so by an attorney. Requests for custody and visitation (parenting time) must generally be filed as part of a case for Separation or Divorce. Revised 11/13/09 Page 2 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Case No.____________________________________ 6. INFORMATION ABOUT CHILD SUPPORT FOR MINOR CHILD(REN): (check one box) An Order for Child Support is dated _____________ from (name of court) which states that child support is established and does not need to be changed. An Order for Child Support is dated _____________from (name of court) _________________________ which states that child support is established and does need to be changed. To my knowledge there is no Child Support Order for the minor child(ren) and the court should order child support in this case along with custody and parenting time. OTHER INFORMATION ABOUT THE 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 I HAVE NOT been a party or a witness in Court in this state or any other state regarding 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: __________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 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: __________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Revised 11/13/09 Page 3 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Case No. _____________________________________ 10. CUSTODY OR PARENTING TIME 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 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: __________________________________________________________________________ OTHER STATEMENTS TO THE COURT: 11. 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. 12. DOMESTIC VIOLENCE: (check if you are asking for joint custody; this statement must be true about you) Domestic violence has not occurred between the parties. 13. VENUE: 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). 14. THE PARENT INFORMATION PROGRAM (PIP) is required for persons seeking custody or parenting time. I have I have not (check one box) already completed the Parenting Information Program REQUESTS I MAKE TO THE COURT IN THIS LAWSUIT: 1. CUSTODY OF MINOR CHILD(REN): (check and complete A or B) Order that: a. SOLE CUSTODY: Sole custody of the minor child(ren) awarded to subject to Parenting Time as follows: me or the other party 1.) Reasonable Parenting Time rights to the parent not having custody, as will be described in a Parenting Plan attached to the Final Order. 2.) Check and explain ONLY if you want the other parent to have Supervised Parenting time OR NO Parenting time): Supervised Parenting Time between the minor child(ren) and me OR the other party; OR NO Parenting Time between the child(ren) and me OR the other party is in the best interests of the minor child(ren), pursuant to A.R.S. Section 25-337 and 25-338, because (explain here reasons for supervision or no Parenting Time): 3) 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)_______________________________ ________________________________________________________________________________ ________________________________________________________________________________ Revised 11/13/09 Page 4 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Case No._____________________________________ The cost of supervised parent/child access shall be paid by: the parent being supervised; the parent having custody; shared equally by the parties. No Parenting Time rights to the parent not having custody, OR: 4.) b. JOINT CUSTODY: Joint Custody - Petitioner and Respondent agree to act as joint custodians of the child(ren), as set forth in the Joint Custody Agreement by the parties pursuant to A.R.S. Section 25-332, signed by both parties, if the Court adopts the agreed terms of the Joint Custody Agreement setting forth the custody and Parenting Time agreement between the parties. There have been no significant acts of Domestic Violence under A.R.S. 13-3601 by either parent. § Check below if you are asking for a child support order or a change of child support in this case: 2. CHILD SUPPORT: Order that child support shall be paid by: (check one box) me or other party in a reasonable amount as determined by the Court under the Arizona Child Support Guidelines (Child Support Order to be attached to the Custody/Parenting Time Order). Support payments shall begin on the first day of the first month following the entry of the Custody/ Parenting Time Order. These payments, plus a statutory fee for handling, shall be paid through the Support Payment Clearinghouse and collected by automatic wage assignment. 3. MEDICAL, DENTAL, VISION CARE: Mother should be responsible for providing: medical dental vision care insurance Father should be responsible for providing: medical dental vision care insurance Medical, dental, and vision care insurance, payments and expenses are based on the information in the Parent’s Worksheet for Child Support attached and incorporated by reference. The party ordered to pay must keep the other party informed of the insurance company name, address and telephone number, and must give the other party the documents necessary to submit insurance claims. Non-Covered Expenses. Petitioner is ordered to pay _______________%, AND Respondent is ordered to pay ______________% of all reasonable uncovered and/or uninsured medical, dental, vision care, prescription and other health care charges for the minor child(ren), including co-payments. 4. OTHER ORDERS I AM REQUESTING (explain request here): __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Revised 11/13/09 Page 5 of 6 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 contents of this document are 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 11/13/09 ______________________________________ Notary Public / Deputy Clerk Page 6 of 6 American LegalNet, Inc. www.FormsWorkFlow.com