Arizona Superior Court, Pinal County Private Juvenile Dependency Cover Sheet Pursuant to Rule 4.1 Superior Court Local Rules - Pinal County, please provide the following information. (Type or print) CASE NUMBER JD 2 Judge PETITIONER'S NAME and ADDRESS MOTHER’S NAME and ADDRESS Name: Name: Relationship to Case: Address: Address: City/State/Zip: City/State/Zip: Telephone: Attorney’s Name and Address: Telephone: PETITIONER'S ATTORNEY’S NAME and ADDRESS: SPECIAL NEEDS IDENTIFICATION & COMMENTS Name/State Bar#: ________ Interpreter needed________________________(language) Address: Comments: ________________________________________________________ ________________________________________________________ ________________________________________________________ City/State/Zip: ________________________________________________________ ________________________________________________________ Telephone: FEES: [ ] PAID [ ] NOT PAID - REASON: [ ] Political Subdivision/Government Agency [ ] Deferred [ ] Waived IS THIS AN INDIAN CHILD? ____ YES ______ NO Tribal Affiliation _____________________________________ Enrollment#:______________________________ Mother DOB:____________ Tribal Affiliation________________________ Enrollment# _____________ Father DOB:____________ Tribal Affiliation________________________ Enrollment# _____________ American LegalNet, Inc. www.FormsWorkflow.com NAMES OF CHILD(REN) & DOB Current Mailing Address Attorney Assigned ______________________________________ _____________________________ ________________________ ______________________________________ ______________________________ ________________________ ______________________________________ ______________________________ ________________________ ______________________________________ ______________________________ ________________________ ______________________________________ ______________________________ ________________________ ______________________________________ ______________________________ ______________________________________ ________________________ ______________________________ ________________________ FATHER’S NAME AND ADDRESS Name: Address: City/State/Zip: Telephone: Attorney’s Name and Address: Agencies involved (JPO or other, please specify)_____________________________________________ To the best of my knowledge, all information is true and correct. ___________________________________________________ Attorney / Pro Per Signature NOTICE Effective September 8, 1992 and pursuant to Superior Court (Pinal County), Administrative Order No. 92-15, the Superior Court requires that a “Cover Sheet”, which categorizes the cause of action, accompany any new action filed with the Superior Court in Pinal County For this purpose, this form has been developed. The cover sheet will result in increased accuracy of courts records and statistics, and and in reduced processing time for new case filings. Forms will be made available at the Clerk of the Superior Court’s Filing Counter. PLEASE DO NOT INCLUDE THIS FORM WITH CASES WHICH HAVE ALREADY BEEN FILED. This form can only be processed at the time of filing New Complaints and Petitions. Thank you for assisting us with our efforts to improve service. Rev 01/26/06 Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com