Free Domestic Relations Cover Sheet - Arizona

Arizona Superior Court, Pinal County
Family Court Cover Sheet
Pursuant to Rule 4.1 Superior Court Local Rules - Pinal County, please provide the following information. (Type or print)

CASE NUMBER DO__________________________
Judge____________________________ ATLAS NUMBER(S)______________________________

PETITIONER'S NAME and ADDRESS Name: Address: City/State/Zip: Phone Number: Email Address: DOB: PETITIONER'S ATTORNEY: Name/State Bar #: Address: City/State/Zip: Telephone: Do you or the other party need an interpreter? Yes No FEES: Name:

RESPONDENT'S NAME and ADDRESS

Address: City/State/Zip: Phone Number: Email Address: DOB: EMERGENCY ORDER SOUGHT: Order of Protection Temporary Order Other __________________________ (Specify)

PAID

NOT PAID - REASON:

If yes, what language:____________________________

Political Subdivision/Government Agency Deferred Waived

ACTION REQUESTED
Check only one box DISSOLUTION (Divorce) D01 With Children D02 Without Children

D11 Legal Separation D12 Paternity/Maternity D13 Annulment D14 Custody D15 Order of Protection D16 Foreign Judgment D17 Domesticated Decree D18 Foreign Judgment for Custody D19 Establish Support D20 Habeas Corpus D21 Visitation D40 Emergency Order of Protection D22 Other___________________ (Specify)
DO1Cover Use only most current version

©Superior Court of Arizona in Pinal County June 22, 2009 ALL RIGHTS RESERVED

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I receive or have received public assistance which may include AFDC, TANF, or AHCCS for my child(ren) or me.

Yes

No

I have a case with the Division of Child Support Enforcement.

Yes

No

If yes, list the case number(s) _________________________________________________________________

Do you currently have ANY other Pinal County Superior Court cases?

Yes

No

If yes, list the case number(s) _________________________________________________________________

Have you ever had ANY other Pinal County Superior Court cases?

Yes

No

If yes, list the case number(s) _________________________________________________________________

PETITIONER'S DECLARATION OF INFORMATION FOR CONCILIATION COURT

The wife is pregnant: The respondent is being served by publication:

Yes Yes

No No

Please enter the number of children under the age of 18 of either or both parties who are in custody of either or both parties: ______

NAMES OF ANY MINOR CHILDREN ___________________________________________ ___________________________________________ ___________________________________________

BIRTH DATES OF MINOR CHILDREN ______________________________ ______________________________ ______________________________ Yes No

There is an agreement as to the parenting arrangements of the minor children:

To the best of my knowledge, all information is true and correct.

Attorney / Pro Per Signature

NOTICE Effective September 8, 1992 and pursuant to Superior Court (Pinal County), Administrative Order No. 92-15, the Superior Court requires that a "Cover Sheet", which categorizes the cause of action, accompany any new action filed with the Superior Court in Pinal County. PLEASE DO NOT INCLUDE THIS FORM WITH CASES THAT HAVE ALREADY BEEN FILED. This form can only be processed at the time of filing New Complaints and Petitions. Revised 6/22/09

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