FOR CLERK’S USE ONLY (a) 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):______________________________ Petitioner Respondent Representing Self SUPERIOR COURT OF ARIZONA MOHAVE COUNTY Case Number: (Name of Petitioner) VOLUNTARY REQUEST FOR ORDER OF PATERNITY (A.R.S. §25-812) AND (Name of Respondent) (b) The parent(s) requests the Clerk to issue an Order establishing paternity for the following child(ren) Full Name on Birth Certificate ______________________________________ ______________________________________ ______________________________________ Date of Birth ___________ ___________ ___________ Place of Birth (City, County, State) ____________________________________ ____________________________________ ____________________________________ The natural mother of the child(ren) was not married when the child(ren) were born or at any time throughout the ten months immediately preceding such birth. This request is based on: (Mark one box only) (c) Affidavit of Acknowledgment: By signing this, we agree and acknowledge that _________________________ is the natural father of the child(ren) named above. Genetic Testing and Laboratory Affidavit: Attached is an affidavit from a certified laboratory indicating that ________________________ has not been excluded as the natural father of the child(ren) and we agree to be bound by the results of this genetic test. The changing of the child(ren’s) name is optional, not mandatory. (d) The parents request the Office of Vital Records amend the birth certificate(s) changing the child(ren)’s name(s) from: to: ______________________________________________ _________________________________________ ______________________________________________ _________________________________________ ______________________________________________ _________________________________________ 11/2/2006 Page 1 of 4 American LegalNet, Inc. www.FormsWorkflow.com Case No.______________________ (e) Mother’s Full Name:__________________________________________________ Date of Birth: _____________ Social Security #: ______________________ (*Can be omitted if using the Confidential Sensitive Data Form) Birthplace (City, State, Country)__________________________________________________________________ Mother’s Maiden Name:_______________________________________________ (f) Father’s Full Name:__________________________________________________ Date of Birth ______________ Social Security #: _____________________ (*Can be omitted if using the Confidential Sensitive Data Form) Birthplace (City, State, Country)__________________________________________________________________ Do not sign this form until you are before the Clerk or Notary Public. ________________________ Date ____________________________________ (g) Mother’s Signature STATE OF ARIZONA ) )ss. COUNTY OF ___________) Acknowledged before me on this date:__________________________ My Commission Expires: _______________________ ____________________________________ NOTARY PUBLIC / DEPUTY CLERK ________________________ Date ____________________________________ (h) Father’s Signature STATE OF ARIZONA ) ss. COUNTY of _____________) Acknowledged before me on this date;__________________________ My Commission Expires: _______________________ 11/2/2006 ____________________________________ NOTARY PUBLIC / DEPUTY CLERK Page 2 of 4 American LegalNet, Inc. www.FormsWorkflow.com AFFIDAVIT OF ACKNOWLEDGMENT OF PATERNITY – (FORM A) IMPORTANT NOTICE! READ THIS BEFORE YOU SIGN: Arizona State Law requires that before voluntarily acknowledging paternity, you be given notice of the alternatives to, the legal consequences of, and the rights and responsibilities that result. Here are some of the things 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 testing done. After you have agreed to voluntarily acknowledge paternity, the Clerk of the Court will issue an order legally establishing the 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 as required under Arizona Law. This order does not decide issues about child support, parenting time (visitation) or custody. 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 custody, unless otherwise ordered by the Court. Arizona Law allows either parent to rescind the acknowledgment of paternity if certain requirements are met. You may have up to sixty days to do this. See § 25-812(H) of the Arizona Revised Statutes. NOTE: * SOCIAL SECURITY NUMBER MUST BE PROVIDED. IT CAN BE OMITTED FROM THIS DOCUMENT AS LONG AS YOU INCLUDE IT ON THE CONFIDENTIAL SENSITIVE DATA FORM (ATTACHED). NAME(S) OF CHILD(REN) BORN OUT OF WEDLOCK: DATE OF BIRTH: ________________________________________________ ________________________________ ________________________________________________ ________________________________ ________________________________________________ ________________________________ ________________________________________________ NATURAL MOTHER & LEGAL CUSTODIAN OF ABOVE NAMED CHILD(REN) _________________________________ *SOCIAL SECURITY NUMBER ________________________________________________ NATURAL FATHER OF ABOVE NAMED CHILD(REN) _________________________________ *SOCIAL SECURITY NUMBER Both Mother and Father hereby acknowledge that __________________________________is the natural mother and ______________________________________ is the natural father of the above-named child(ren). 11/2/2006 Page 3 of 4 American LegalNet, Inc. www.FormsWorkflow.com Case No:_________________ We swear or affirm that the information on this document is true and correct to the best of our knowledge and belief. _____________________________ Date ___________________________________________ (Mother’s Signature STATE OF ARIZONA ) )ss: COUNTY OF _________________ ) Subscribed and sworn or affirmed and acknowledged before me this date:______________________ My Commission Expires:____________________ ___________________________________________ NOTARY PUBLIC / DEPUTY CLERK _____________________________ Date ___________________________________________ (Father’s Signature) STATE OF ARIZONA ) )ss: COUNTY OF _________________ ) Subscribed and sworn or affirmed and acknowledged before me this date:______________________ My Commission Expires::________________ ___________________________________ NOTARY PUBLIC/DEPUTY CLERK 11/2/2006 Page 4 of 4 American LegalNet, Inc. www.FormsWorkflow.com