S STATE OF ARIZONA O OFFICE OF VITAL RECORDS COURT ORDERED DELAYED BIRTH REGISTRATION FOR OFFICE USE ONLY DATE RECEIVED BY STATE OFFICE W WRITE NEATLY. USE BLACK INK. Do NOT use cross-outs, write-overs, erasures, correction fluid, or correction tape. If a mistake is made, prepare a new form. If you have any questions regarding this form, call (602) 364-1300 or (602) 364-2429. PART 1: BIRTH FACTS OF REGISTRANT NAME AT BIRTH: FIRST MIDDLE LAST (BEFORE MARRIAGE) SUFFIX RACE (SELECT FROM LIST IN SECTION A ON NEXT PAGE) SEX DATE OF BIRTH: MONTH DAY YEAR PLACE OF BIRTH: TOWN OR CITY COUNTY STATE ARIZONA PART 2: INFORMATION ABOUT NATURAL PARENTS OF REGISTRANT FATHER222S NAME: FIRST MIDDLE LAST SUFFIX PLACE OF BIRTH (STATE OR COUNTRY) DATE OF BIRTH SOCIAL SECURITY NUMBER RACE IS S THE FATHER OF HISP ANIC ORIGIN ? ? Y Y ES N O ; ; IF YES, PLEASE SELECT ORIGIN FROM SECTION B ON NEXT PAGE AND ENTER MOTHER222S NAME: FIRST MIDDLE LAST NAME (BEFORE FIRST MARRIAGE) I S S THE MOTHER OF HISP ANIC ORIGIN ? ? Y E ES N O O ; I I F, YES , PLEASE SELECT ORIGIN FROM SECTION B ON NEXT PAGE AND ENTER HERE: CURRENT LEGAL LAST NAME PLACE OF BIRTH (STATE OR COUNTRY) DATE OF BIRTH SOCIAL SECURITY NUMBER RACE MOTHER222S RESIDENCE AT THE TIME OF BIRTH (STREET ADDRESS) CITY/TOWN STATE COUNTRY WAS MOTHER222S RESIDENCE A TRIBAL COMMUNITY? YES NO IF YES, PLEASE SELECT THE TRIBAL COMMUNITY FROM SECTION C ON NEXT PAGE AND ENTER YOUR SELECTION HERE: PART 3: DOCUMENTARY EVIDENCE AND INFORMATION ACCEPTED BY THE COURT DATE ESTABLISHED TYPE OF DOCUMENT/EVIDENCE DATE ESTABLISHED TYPE OF DOCUMENT/EVIDENCE DATE ESTABLISHED TYPE OF DOCUMENT/EVIDENCE DATE ESTABLISHED TYPE OF DOCUMENT/EVIDENCE OTHER INFORMATION DESCRIBE: SIGNATURE OF REGISTR A ANT/OTH ER (REGISTRANT MUST BE 18 YEARS OF AGE OR OLDER OR EMANCIPATED TO SIGN) By signing this document, you are verifying the information provided on this form is true and accurate. SIGNATURE OF (CHECK ONE) REGISTRANT OTHER DATE SIGNED CONTINUES ON NEXT PAGE PRINTED NAME American LegalNet, Inc. www.FormsWorkFlow.com P PART 4: CERTIFICATION OF CLERK OF THE COURT CERTIFICATION OF CLERK OF THE COURT A FINAL ORDER TO ESTABLISH A DELAYED BIRTH CERTIFICATE WAS GRANTED IN THE SUPERIOR COURT OF THIS STATE ON 20 IN CASE NO. JUDGEPRESIDING DATE SIGNED BY CASE NO. CLERK FOR COUNTY OF CLERK OF COURT (IMPRESS COURT SEAL HERE UPON COMPLETION, MAIL BOTH PAGE 1 1 AND 2 OF THIS DOCUMENT TO: OFFICE OF VITAL RECORDS P.O. BOX 6018 PHOENIX, AZ 85030 N:Groups/Admin/Birth Registry/Forms/court ordered delayed birth registration 07-19-07 226 MS Word, Revised: 7/19/07 American LegalNet, Inc. www.FormsWorkFlow.com Court Ordered Delayed Birth Registration Instruction Guide American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com