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Form 4. Affidavit Regarding a Minor Child [Number assigned by publisher]

Arizona Revised Statutes AnnotatedLocal Rules of Practice Superior Court

Arizona Revised Statutes Annotated
Local Rules of Practice Superior Court (Refs & Annos)
Pima County (Refs & Annos)
Forms
17C A.R.S. Super.Ct.Local Prac.Rules, Pima County, Form 4
Form 4. Affidavit Regarding a Minor Child [Number assigned by publisher]
Currentness
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) Empty Checkbox​
Non-blood Relative Empty Checkbox​
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:
Empty Checkbox​
Date of death:
 
Incarcerated:
Empty Checkbox​
Expected date of release:
 
Never married to child's father:
Empty Checkbox​
Married to child's father:
Empty Checkbox​
Divorced (include pending
divorces) from child's father:
Empty Checkbox​
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:
Empty Checkbox​
Date of death:
 
Incarcerated:
Empty Checkbox​
Expected date of release:
 
Never married to child's mother:
Empty Checkbox​
Married to child's mother:
Empty Checkbox​
Divorced (include pending
divorces) from child's mother:
Empty Checkbox​
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.
Empty Checkbox​
Empty Checkbox​
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.
Empty Checkbox​
Empty Checkbox​
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.
Empty Checkbox​
Empty Checkbox​
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.
Empty Checkbox​
Empty Checkbox​
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 Empty Checkbox​
No Empty Checkbox​
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 Empty Checkbox​
No Empty Checkbox​
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 Empty Checkbox​
No Empty Checkbox​
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

Credits

Added and effective on emergency basis Sept. 28, 2005. Adopted in final form Jan. 20, 2006.
17C A. R. S. Super. Ct. Local Prac. Rules, Pima County, Form 4, AZ ST PIMA SUPER CT Form 4
State Court Rules are current with amendments received through April 1, 2024. The Code of Judicial Administration is current with amendments received through April 1, 2024.
End of Document