FOR CLERK'S USE ONLY (1) Name of Person Filing: _______________________________________ Mailing Address: _______________________________________ City, State, Zip Code: _______________________________________ Daytime Phone Number: _______________________________________ Evening Phone Number: _______________________________________ (2) ATLAS Number (if applicable):____________________________________ Attorney Bar Number (if applicable):__________________________________ Self (No Attorney) OR Attorney Representing: SUPERIOR COURT OF ARIZONA MOHAVE COUNTY (3) Person filing (Petitioner) (4) Case Number:___________________________ VOLUNTARY ACKNOWLEDGMENT OF PATERNITY (A.R.S. §25-812) ________________________________ Other Parent (Respondent) (5) The Clerk is requested to issue an order establishing paternity for the following minor children: NAME(S) First (a)____________________________ (b)____________________________ (c)____________________________ Middle ____________________________ ____________________________ ____________________________ (new) Last _____________________________ _____________________________ _____________________________ who were born on this date and at this location (below): (List in same order as above.) Month / day / year (a)____________________________ (b)____________________________ (c)____________________________ City, State, Nation of Birth ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ (6) Mother's full Name ____________________________________________________________________________ Maiden Name ____________________________________ Date of Birth _____________________________ The natural mother of the minor children was not married at the time of birth or at any time during the ten months prior to birth. The natural father is: (7) Father's Full Name ____________________________________________________________________________ Date of Birth _____________________________ Birthplace (City, State, Country) __________________________________________________________________ Current Address ____________________________________________________________________________ The parents request the court to order the Office of Vital Records to amend the birth certificate(s) to correct the name of the father. (8) We base this request on: (Mark only one) Affidavit of Acknowledgment, by which we agree and acknowledge the natural father named above. Genetic (DNA) Testing and Laboratory Affidavit: Attached is an affidavit from a certified laboratory indicating that the father named above has not been excluded as the natural father of the children and we agree to be bound by the results of the genetic test. Revised: 1/1/2013 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Case No._________________________________ (9) The parents request the court to order the Office of Vital Records to amend the birth certificate(s) to change the minor child(ren)'s name(s) to: (List in same order as (5)). (Optional)) (New Names) (a)____________________________ (b)____________________________ (c)____________________________ ____________________________ ____________________________ ____________________________ _____________________________ _____________________________ _____________________________ IMPORTANT NOTICE: READ THIS BEFORE YOU SIGN: Arizona law requires that before voluntarily acknowledging paternity, you be given notice of the alternatives to, legal consequences of and the rights and responsibilities that result. You should know: · No one is required to voluntarily acknowledge paternity. · You have the right to seek legal advice before signing this document, and · If you are unsure who the father is, an alternative is to have genetic (DNA) testing done. After you submit this Voluntary Acknowledgement of Paternity, the Clerk of Court or authorized personnel will issue an order legally establishing the natural father. This Order is the same as a judgment of the Superior Court. After the Order is issued both parents will have all the rights and responsibilities of parents required by Arizona law. The Order does not decide issues about child support, parenting time (visitation), or legal decision making. However the Order includes a statement of Arizona law that the parent with whom the child has resided for the greater part of the last six months shall have legal decision making unless otherwise ordered by the Court. Arizona law allows either parent to rescind the acknowledgment of paternity if certain requirements are met. See §25-812(H) of the Arizona Revised Statutes for the requirements. This document can be notarized OR witnessed. Witness must be at least 18 years of age and not related to either parent by blood or marriage. Sign only in presence of Witness, Deputy Clerk of Court, or Notary. STATE OF ARIZONA ) )ss: County of Mohave ) ____________________________________________ (10) Signature of Mother Date ____________________________________________ Signature of Witness Date ____________________________________________ Printed name of Witness ____________________________________________ Address of Witness ____________________________________________ City, State, Zip Code Acknowledged before me this:____________________ ____________________________________________ Deputy Clerk or Notary Seal/My commission expires: ____________________ Revised: 1/1/2013 ____________________________________________ (10) Signature of Father Date ____________________________________________ Signature of Witness Date ____________________________________________ Printed name of Witness ____________________________________________ Address of Witness ____________________________________________ City, State, Zip Code Acknowledged before me this:____________________ ____________________________________________ Deputy Clerk or Notary Seal/My commission expires: ____________________ Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com