Affidavit Regarding Minor Child

Attorney's Name: Computer Number: Party Name: Address: City, State, and Zip: Telephone Number: __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ ARIZONA SUPERIOR COURT, PIMA COUNTY IN THE MATTER OF: Name: (from birth certificate) ___________________________________ Date of birth: ___________________________________ A MINOR Case Number: AFFIDAVIT REGARDING MINOR CHILD 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, _______________________, have read the above warning, Dated: _______________________ American LegalNet, Inc. www.USCourtForms.com Signed: _______________________ 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) Non-blood Relative 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) 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. 4. 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: Provide place, date, and case number of dissolution proceeding. Place: ______________________________ Date: ______________________________ Case Number: ______________________________ 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: Date of death Expected date of release Provide place, date, and case number of dissolution proceeding. Place: ______________________________ Date: ______________________________ Case Number: ______________________________ 6. 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 pursua