Arizona Supreme Court Page 1 of 6 JE12F-031516 Person Filing: Address (if not protected): City, State, Zip Code: Telephone: Email Address: Representing [ ] Self or [ ] Lawyer for Lawyer222s Bar Number: SUPERIOR COURT OF ARIZONA IN COUNTY In the Matter of the Emancipation of: Case Number: PETITION FOR EMANCIPATION OF A MINOR A.R.S. 247 12-2451 A Minor [ ] Female [ ] Male STATEMENTS TO THE COURT UNDER OATH OR BY AFFIRMATION I am at least 16 years old. I am a resident of Arizona and of the county where I am filing this request. I am financially self-sufficient; I am able to support myself and provide for my own food, housing, and medical care. I have read and understood the information provided by the Court that explains the rights and obligations of an emancipated minor and the potential risks and consequences of emancipation. I am not a ward of the court: I am not on probation or parole, or in the care or custody of DCS or other state agency, and no final order of 223Dependency224 has been entered. 1. PERSONAL INFORMATION ABOUT ME, 223THE MINOR224, REQUESTING EMANCIPATION: My Name (First, Middle, Last): Mailing Address: City, State, Zip Code: Day/Evening Telephone: ( ) / ( ) Date of Birth (Month/Date/Year): For Clerk222s Use Only American LegalNet, Inc. www.FormsWorkFlow.com Case Number: Arizona Supreme Court Page 2 of 6 JE12F-031516 2. PERSONS ENTITLED TO NOTICE of this matter as required by the Court and under Arizona law, A.R.S. 12-2451. If applicable, check the box for 223Parental Rights Terminated by Court Order224 or 223Deceased.224 If 223Deceased224, attach proof such as death certificate or obituary notice. MOTHER Name: [ ] Deceased [ ] Parental Rights Terminated by Court Order Mailing Address: City, State, Zip Code: Day/Evening Telephone: ( ) / ( ) FATHER Name: [ ] Deceased [ ] Parental Rights Terminated by Court Order Mailing Address: City, State, Zip Code: Day/Evening Telephone: ( ) / ( ) LEGAL GUARDIAN Name: [ ] Deceased [ ] Parental Rights Terminated by Court Order Mailing Address: City, State, Zip Code: Day/Evening Telephone: ( ) / ( ) LEGAL GUARDIAN Name: [ ] Deceased [ ] Parental Rights Terminated by Court Order Mailing Address: City, State, Zip Code: Day/Evening Telephone: ( ) / ( ) 3. I CURRENTLY HAVE ONE OR MORE LEGAL GUARDIANS BECAUSE: Explain what happened to cause someone to request to be appointed your guardian or the reasons or circumstances that caused the Court to appoint your guardian(s). American LegalNet, Inc. www.FormsWorkFlow.com Case Number: Arizona Supreme Court Page 3 of 6 JE12F-031516 FACTS TO SUPPORT MY REQUEST FOR EMANCIPATION: The following answers and statements explain how I will handle my financial, personal, and social affairs, provide for my own food, housing and medical care, maintain my educational or vocational training, and my employment situation. 4. My Street Address: City, State, Zip Code: I have been living there since: (Month/Date/Year) 5. I live there with (name and relationship of all persons, including children): 6. a. [ ] I attend (name of school) and I am in the grade. b. [ ] I am not in school. The highest grade of education I have completed is grade. c. My plans concerning education or job training are as follows: 7. a. [ ] I am not receiving public assistance or TANF and I do not intend to apply for either. b. [ ] I am receiving public assistance or TANF. The monthly amount received is: $ c. [ ] I have applied for or intend to apply for public assistance or TANF. 8. a. [ ] I am currently employed by: Employer # 1 (Attach pay stub) Address: Telephone: ( ) I started work (month/year): Job Title: Employer # 2 (Attach pay stub) Address: Telephone: ( ) I started work (month/year): Job Title: American LegalNet, Inc. www.FormsWorkFlow.com Case Number: Arizona Supreme Court Page 4 of 6 JE12F-031516 b. [ ] I am not currently employed. I last worked: From: (starting month, year) To: (ending month and year) My gross monthly earnings (before taxes or other deductions) were: $ 9. My average gross monthly income (annual amount divided by 12) is shown below. Amount a. Salary / Wages, including bonuses and overtime, before taxes or other deductions $ b. Money received from others (List name, your relationship to those persons, and amounts) Name, Relation: $ Name, Relation: $ c. Social Security Survivor Benefits (received due to death of a parent) $ d. Social Security Disability Benefits $ e. Child Support Received for MY Children $ f. Other source of income (specify source) $ g. TOTAL MONTHLY INCOME: (Add 9 a-f) $ 10. I have the following assets (things of value that I own): Value a. Cash $ b. Checking Account(s) (total, if more than one) $ c. Savings Account(s) (total, if more than one) $ d. Stocks, Bonds $ e. Trust Fund(s) (total, if more than one) $ f. Vehicle (Year, Make, and Model): $ g. Other (specify) $ h. TOTAL VALUE OF ASSETS: (Add 10 a-g) $ 11. I have the following monthly expenses: Amount a. Housing $ b. Food (groceries plus dining out) $ c. Clothing $ d. Utilities (phone plus electric, gas, cellular, water & sewer) $ e. Medical 1. Insurance $ 2. Doctor, dentist, hospital, urgent care $ American LegalNet, Inc. www.FormsWorkFlow.com Case Number: Arizona Supreme Court Page 5 of 6 JE12F-031516 3. Prescription medications $ 4. Total Medical Expenses (add 1-3) $ f. Transportation (public transit, bus and taxi) $ g. Vehicle 1. Monthly payments $ 2. Insurance $ 3. Fuel/gasoline $ 4. Service, maintenance and repair $ 5. Total Vehicle Expenses (add 1-4) $ h. Child Support Paid for my Children (Amount I pay to someone else) $ i. Other (specify) $ j. TOTAL MONTHLY EXPENSES: (Add 11 a-i) $ 12. I will provide for my health care through [ ] insurance through employer [ ] AHCCS [ ] Other. If 223Other224, explain: 13. At least one of the following is included with this request: (At least one box must be checked; you may check and attach more than one to further support your request.) [ ] Attached is documentation that I have been living on my own for at least three consecutive months. [ ] Attached is a statement explaining why I believe the home of my parent(s) or legal guardian(s) is NOT a healthy or safe environment. [ ] Attached is a notarized statement by one or more of my parent(s) and/or legal guardian(s) that contains written consent to my emancipation and explanation. American LegalNet, Inc. www.FormsWorkFlow.com Case Number: Arizona Supreme Court Page 6 of 6 JE12F-031516 14. I am aware that the Court may refer me and any parent or guardian to mediation. (Optional) [ ] I believe mediation is not appropriate because of family violence or: REQUESTS TO THE COURT 15. I REQUEST THE COURT ENTER AN ORDER FOR MY EMANCIPATION. UNDER OATH OR BY AFFIRMATION I swear or affirm under penalty of perjury that the contents of this document are true and correct to the best of my knowledge and belief. Date Petitioner222s Signature STATE OF COUNTY OF Subscribed and sworn to or affirmed before me this: (date) by . (notary seal) Deputy Clerk or Notary Public American LegalNet, Inc. www.FormsWorkFlow.com