Page 1 of 5 DOPTMCOSCPinal03.09.18 Use only most current version Name of Person Filing: Street Address: City, State, Zip Code: Telephone Number: Email Address: ATLAS Number (if applicable) Representing Self (No Attorney) or Represented by Attorney If Attorney, Bar Number: SUPERIOR COURT OF ARIZONA PINAL COUNTY CASE NUMBER: S1100 Name of Petitioner PETITION TO MODIFY: (CHECK ONE) Parenting Time Only Parenting Time and Child Support Name of Respondent HONORABLE: GENERAL INFORMATION: I, am the Petitioner / Respondent / Other and make the following statements to the Court, under oath: 1.Information about Me, the person filing this modification: Name: Address: How I am related to child(ren) for whom Parenting Time order should be changed: Mother Father or Other (explain) American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 5 DOPTMCOSCPinal03.09.18 Use only most current version 2.Information about the Other Parent: (if the person filing this modification is one of the parents. If someone other than one of the parents is filing this request, then list the information about one of the parents, then the information about the other parent below). Name: Address: How this party is related to child(ren) for whom Parenting Time order should be changed: Mother Father Information about the Other Parent or Other Party: (if there is a non-parent involved in the case other than the person whose information has already been listed in (1) above: Name: Address: How the other party is related to child(ren) for whom Parenting Time order should be changed: Mother Father or Other (explain) 3.Information about the child(ren) for whom I want the parenting time order changed: Child222s Name: Birth Date: Age: Child222s Name: Birth Date: Age: Child222s Name: Birth Date: Age: Child222s Name: Birth Date: Age: 4.Affidavit Regarding Minor Children. The children have resided in Arizona since the entry of the last Arizona City Order and I have completed an 223Affidavit Regarding Minor Children224 or if not I have completed an 223Affidavit Regarding Minor Children224. 5.Information about the Order I want to change. The Order was issued on (Month, Day, Year) The Order was issued by: (Name of Court) Located in this County: (Name of County) Located in this State: (Name of State) American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 5 DOPTMCOSCPinal03.09.18 Use only most current version And each of the following is a true statement: The child(ren) has lived in Arizona for at least six (6) months before the date I am filing this Petition. If the Order was not issued by the Superior Court of Arizona in this county, the case has already been transferred to this county and has a Pinal County case number. 6.Domestic Violence No significant domestic violence has occurred, or domestic violence has occurred. Explain: 7.WHAT YOUR ORDER NOW SAYS: Put in WORD for WORD the part of the decree / order you want to change. (Use extra paper if necessary) OR incorporate the Order, which is already a part of the court222s file and attached a copy of the Order to the judge222s copy of this Petition and all parties222 copies of this Petition. 8.WHY THE DECREE / ORDER SHOULD BE CHANGED: These are my reasons why I believe that a change of parenting time is in the best interest of the child(ren). Use extra pages if necessary): 9.MEDIATION REQUIREMENTS IN PRIOR ORDER: The current Court Order does not require the parties to pursue Mediation before filing to modify (change) legal decision-making or parenting time OR American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 5 DOPTMCOSCPinal03.09.18 Use only most current version The current Court Order does require the parties to pursue Mediation before filing to modify (change) legal decision-making or parenting time and this is what I / we have done to comply with that requirement: REQUESTS I MAKE TO THE COURT: A. PARENTING TIME to the Mother Father or Other (non-parent) 1. Reasonable Parenting Time to the parent/party who does not have legal decision-making according to the Parent/Child Parenting time/Access Guidelines; OR 2. Reasonable Parenting Time to the parent/party who does not have legal decision-making according to the attached Parenting Plan; OR 3. Supervised Parenting Time but only in the presence of another person. Name of person to supervise parenting time: OR 4. No Parenting Time rights to Mother or Father Supervised parenting time or no parenting time is requested for the following reasons: The costs of travel related to parenting time / visitation over 100 miles one way shall be shared as follows: Mother % Father % B. CHILD SUPPORT Mother Father should pay child support to the other party in the amount of $ per month on the first day of every month based upon the 223Parent222s Worksheet224 filed with Petition to Modify Parenting time. All child support payments should be made through the Child Support Clearinghouse and will be subject to an applicable statutory fee through an automatic Income Withholding Order/Notice for Support. American LegalNet, Inc. www.FormsWorkFlow.com Page 5 of 5 DOPTMCOSCPinal03.09.18 Use only most current version C. MEDICAL, DENTAL and VISION INSURANCE PAYMENTS AND EXPENSES Mother is responsible for providing: Medical Dental Vision care insurance. Father is responsible for providing: Medical Dental Vision care insurance. Parties should be ordered to pay for all reasonable unreimbursed medical, dental, health-related expenses incurred for the child(ren) in proportion to their respective incomes or % by Mother and % by Father. D. INCOME TAX DEDUCTIONS Child222s Name Date of Birth (Month, Day, Year) Parent Entitled to Deduction For Calendar Year Mother Father Mother Father Mother Father Mother Father E. OTHER ORDERS I request further Orders relating to this matter as follows: OATH OR AFFIRMATION AND VERIFICATION I SWEAR OR AFFIRM that the information on this Petition to Modify ( ) Parenting Time or ( ) Parenting Time and Child Support is true and correct under penalty of perjury. (Date) (Signature of Person filing Petition SWORN to or Affirmed before me this of 20 . My Commission Expires: Deputy Clerk or Notary Public American LegalNet, Inc. www.FormsWorkFlow.com