Name: ___________________________________ Address: _________________________________ City, State, ZIP: ____________________________ Daytime Telephone No: ______________________ Representing Self, Without a Lawyer ARIZONA SUPERIOR COURT, PIMA COUNTY ______________________________________ Case No. _________________ Petitioner/Plaintiff and AFFIDAVIT RE: MINOR CHILDREN ______________________________________ Respondent/Defendant STATE OF ARIZONA County of Pima 1. ) ) ss. ) The nature of this action is: Dissolution Legal Separation is Paternity Annulment Child Custody Modification 2. The mother is not presently pregnant. 3. There are are not minor children of either or both of the parties in this case who are in the custody of either or both of the parties. 4. I have have not participated as a party, witness, or in any other capacity in any other prior litigation concerning custody of a child mentioned below, in this or any other state. (If you have, state the name of each child, the manner in which you participated, the court, the state & county or district, case number, and date of order or judgment, if any.) ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 5. I do do not have any information of any custody proceeding concerning a child mentioned below pending in a court of this or any other state. (If you do, state the name of each child, nature of the proceeding, the court, the state & county or district, case number, and the status of the proceeding.) ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 1 dwcpetition-nottice re health ins.info Revised 07.23.09 American LegalNet, Inc. www.FormsWorkFlow.com 6. I do do not know of any person not a party to this proceeding who has physical custody or claims to have custody or visitation rights with respect to any child mentioned below. (If you do have such knowledge, state the name and address of the person, whether that person has physical custody, is claiming custody rights, or is claiming visitation rights, and the name of the child involved.) ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 7. Mother's mailing address is: _______________________________________________________________ 8. Father's mailing address is: _______________________________________________________________ 9. a) The minor child(ren) affected or of this action are: NAME BIRTHDATE BIRTHPLACE ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ b) All the children have resided together at the following locations during the last five years: DATES OF RESIDENCE ADDRESS OF CHILD DURING PERIOD NAME AND PRESENT ADDRESS OF PERSON HAVING PHYSICAL CUSTODY DURING RESIDENCE PERIOD RELATION TO CHILD ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ NOTE: If any of the children have lived separately, give specific information for that child on an additional page. ________________________________________ Plaintiff Defendant SUBSCRIBED AND SWORN to before me this _____ day by ___________________________________________________. My Commission Expires: , 20 __ _________________________________________ Notary Public ____________________ 2 dwcpetition-nottice re health ins.info Revised 07.23.09 American LegalNet, Inc. www.FormsWorkFlow.com