Rule 4. Sessions of Superior Court Outside County Seat

Attorney's Name: ______________________________ Computer Number: ______________________________ Party Name: ______________________________ Address: ______________________________ City, State, and Zip: ______________________________ Telephone Number: ______________________________ ARIZONA SUPERIOR COURT, PIMA COUNTY IN THE MATTER OF: ) ) Case Number: Name: (from birth certificate) ) ) ) AFFIDAVIT ) REGARDING MINOR Date of birth: ) CHILD ) ) A MINOR ) ) 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, Signed: Dated: 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, great- grandparent, 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) rent 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: ​ Date of death: Incarcerated: ​ Expected date of release: Never married to child's father: ​ Married to child's father: ​ 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: ​ Date of death: Incarcerated: ​ Expected date of release: Never married to child's mother: ​ Married to child's mother: ​ Divorced (include pending divorces) from child's mother: ​ Provide place, date, and case number of dissolution proceeding. Place: Date: Case Number: 6. Answer the following questions as true or false. True False The child's parents have a pending divorce (dissolution of marriage) case in this, or any other, court. ​ ​ If true, explain. Provide the date, state, county, case number, and outcome of the case. True False An order granting custody or visitation to either of the child's parents has been made in this, or any other, court. ​ ​ If true, explain. Provide the date, state, county, case number, and outcome of the case. True False I have been a party or witness in a court proceeding regarding visitation or custody of the above child. ​ ​ If true, explain nty, case number, and outcome of the case. True False An order granting custody or visitation to either of the child's parents has been made in this, or any other, court. ​ ​ If true, explain. Provide the date, state, county, case number, and outcome of the case. True False I have been a party or witness in a court proceeding regarding visitation or custody of the above child. ​ ​ If true, explain. Provide the date, state, county, case number, and outcome of the case. True False I have knowledge of a court proceeding concerning visitation or custody of the above child. ​ ​ 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. 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 pursuant to Title 25 (Marital and Domestic Relations) of Arizona Revised Statutes. Yes ​ No ​ If true, explain. Provide the date, state, county, case number, and outcome of the case. 10. State the name of the person (and their relationship to the child) with whom the child has been living during the past seven days. State the address where the child has been living during the past 7 days y brought pursuant to Title 25 (Marital and Domestic Relations) of Arizona Revised Statutes. Yes ​ No ​ If true, explain. Provide the date, state, county, case number, and outcome of the case. 10. State the name of the person (and their relationship to the child) with whom the child has been living during the past seven days. State the address where the child has been living during the past 7 days. The undersigned swears under penalty of perjury that the above statements are true and correct. Print Name: _____________________________________ Signed: _____________________________________ Date: _____________________________________ SUBSCRIBED AND SWORN TO before me on: Date: _____________________________________ Signed: _____________________________________ Notary Public / Deputy Clerk of Court My commission expires: _____________________________________ Seal or stamp inside box