Attorney’s Name: __________________________________ Computer Number: __________________________________ Party Name: __________________________________ Address: __________________________________ City, State, and Zip: __________________________________ Telephone Number: __________________________________ ARIZONA SUPERIOR COURT, PIMA COUNTY IN THE MATTER OF: Case Number: Name: (from birth certificate) ___________________________________ Date of birth: ___________________________________ AFFIDAVIT REGARDING MINOR CHILD A MINOR WARNING – READ AND SIGN By filing this affidavit with the court, you are stating under penalty of perjury that the statements contained herein are true to the best of your knowledge. If you state facts in this affidavit which you know to be false, you may be subject to serious penalties. Such penalties may include, but are not limited to, criminal prosecution for perjury, and/or a finding of criminal contempt. Perjury is a felony for which a term of four years in prison may be imposed. A person may be incarcerated for up to four months if found to be in criminal contempt of court. I, _______________________, Signed: _______________________ have read the above warning, Dated: _______________________ American LegalNet, Inc. www.USCourtForms.com I, _________________________________ declare under oath and under penalty of perjury: 1. The child’s name: The child’s date of birth: The child’s place of birth: ___________________________ ___________________________ ___________________________ 2. What is your relationship to the child? ___________________________ Are you a blood relative of the child? A blood relative is any one of the following: parent, sibling (i.e. brother or sister with at least one parent in common), grandparent, greatgrandparent, aunt, or uncle (if he or she shares a common parent with either of the minor's parents). Blood Relative (including adoption)  3.  List all places where the child lived during the past five years. List also the name and current address of the person who had physical custody of the child during that period. Period (from mm/yy) to (mm/yy) 4. Non-blood Relative Address (include street, unit number, city, state, and country if outside United States). Current name and address of person having physical custody of child during this period. Relationship to child. Please provide the following information regarding the child’s biological (or adoptive) mother? Name: _____________________ Address: Check each of the following that apply Deceased:  Incarcerated:  Never married to child’s father:  Married to child’s father:  ____________________________________ ____________________________________ Date of death: Expected date of release: __________________ __________________ American LegalNet, Inc. www.USCourtForms.com Divorced (include pending divorces) from child’s father:  5. Please provide the following information regarding the child’s biological (or adoptive) father? Name: _____________________ Address: Check each of the following that apply Deceased:  Incarcerated:  Never married to child’s mother:  Married to child’s mother:  Divorced (include pending divorces) from child’s mother:  6. Provide place, date, and case number of dissolution proceeding. Place: ______________________________ Date: ______________________________ Case Number: ______________________________ ____________________________________ ____________________________________ Date of death Expected date of release __________________ __________________ Provide place, date, and case number of dissolution proceeding. Place: ______________________________ Date: ______________________________ Case Number: ______________________________ Answer the following questions as true or false. True The child’s parents have a pending divorce (dissolution of marriage) case in this, or any other, court. False   If true, explain. Provide the date, state, county, case number, and outcome of the case. ______________________________________________________________________________ ______________________________________________________________________________ True An order granting custody or visitation to either of the child’s parents has been made in this, or any other, court. False   If true, explain. Provide the date, state, county, case number, and outcome of the case. ______________________________________________________________________________ ______________________________________________________________________________ American LegalNet, Inc. www.USCourtForms.com True I have been a party or witness in a court proceeding regarding visitation or custody of the above child. False   If true, explain. Provide the date, state, county, case number, and outcome of the case. ______________________________________________________________________________ ______________________________________________________________________________ True I have knowledge of a court proceeding concerning visitation or custody of the above child. False   If true, explain. Provide the date, state, county, case number, and outcome of the case. ______________________________________________________________________________ ______________________________________________________________________________ 7. Are you aware of proceedings in any court which exercises jurisdiction over matters involving children or juveniles, including the Juvenile Court in Pima County. These matters include dependency, delinquency, and proceedings relating to juvenile offenders. Yes  No  If true, explain. Provide the date, state, county, case number, and outcome of the case. ______________________________________________________________________________ ______________________________________________________________________________ 8. Are you aware of any guardianship proceeding, in this or any other state, involving this child? These proceedings include petitions for guardianship brought pursuant to Title 14 (Probate) of Arizona Revised Statutes. Yes  No  If true, explain. Provide the date, state, county, case number, and outcome of the case. ______________________________________________________________________________ ______________________________________________________________________________ American LegalNet, Inc. www.USCourtForms.com 9. Are you aware of any proceedings, in this or any other state to establish custody or visitation by a non-parent, including this child’s grandparent(s). These proceedings include any petition for custody brought pursuant to Title 25 (Marital and Domestic Relations) of Arizona Revised Statues. Yes  No  If true, explain. Provide the date, state, county, case number, and outcome of the case. ______________________________________________________________________________ ______________________________________________________________________________ 10. State the name of the person (and their relationship to the child) with whom the child has been living during the past seven days. State the address where the child has been living during the past 7 days. ______________________________________________________________________________ ______________________________________________________________________________ The undersigned swears under penalty of perjury that the above statements are true and correct. Print Name: _________________________________ Signed: _________________________________ Date: _________________________________ SUBSCRIBED AND SWORN TO before me on: Date: _________________________________ Signed: _________________________________ Notary Public / Deputy Clerk of Court My commission expires: _________________________________ Seal or stamp inside box American LegalNet, Inc. www.USCourtForms.com