Free Petition for Emancipation of a Minor - Arizona

For Clerk's Use Only

Person Filing: Mailing Address: City, State, Zip: Day/Evening Phone: Person Filing is: If Attorney, Bar No.:

/ SELF (No Attorney) OR Attorney Atty. Phone:

IN

SUPERIOR COURT OF ARIZONA COUNTY JUVENILE COURT
Case Number: PETITION FOR EMANCIPATION OF A MINOR
A.R.S. § 12-2451

In the Matter of the Emancipation of:

A Minor

STATEMENTS TO THE COURT UNDER OATH OR BY AFFIRMATION
· · · · · I am at least 16 years old. I am a resident of Arizona and of the county where I am filing this request. I am financially self-sufficient; I am able to support myself and provide for my own food, housing, and medical care. I have read and understand the information provided by the Court that explains the rights and obligations of an emancipated minor and the potential risks and consequences of emancipation. I am not a ward of the court: I am not on probation or parole, or in the care or custody of CPS or other state agency, and no final order of "Dependency" has been entered.

1. PERSONAL INFORMATION ABOUT ME, "THE MINOR", REQUESTING EMANCIPATION:
My Name: First Mailing Address:
City, State, Zip Code:

Middle

Last

Daytime/Evening Telephone: ( Date of Birth: (Month)

)

/(

)

(Day

(Year)

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2. PERSON(S) ENTITLED TO NOTICE of this matter under Arizona law, A.R.S. 12-2451:
If applicable, check the box for "Parental Rights Terminated by Court Order" or "Deceased" and attach proof (e.g. copy of order terminating parental rights, copy of death certificate or obituary notice). MOTHER Name: Deceased Mailing Address: City, State, Zip Code: Daytime/Evening Telephone: FATHER Name: Deceased Mailing Address: City, State, Zip Code: Daytime/Evening Telephone LEGAL GUARDIAN Name: Mailing Address: City, State, Zip Code: Daytime/Evening Telephone LEGAL GUARDIAN Name: Mailing Address: City, State, Zip Code: Daytime/Evening Telephone ( ) / ( ) ( ) / ( ) Deceased ( ) / ( ) Deceased Parental Rights Terminated by Court Order ( ) Parental Rights Terminated by Court Order

EXPLAIN IN THE SPACE PROVIDED WHY YOU HAVE A GUARDIAN:

FACTS TO SUPPORT MY REQUEST FOR EMANCIPATION: The following answers and statements explain how I will handle my financial, personal and social affairs; provide for my own food, housing and medical care; and maintain my educational or vocational training and my employment situation. 3. MY STREET ADDRESS:
City, State, Zip code I have been living there since: (month / date / year) Page 2 of 5
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4.

I LIVE THERE WITH (name and relationship of all persons, including children):

5.

EDUCATION:
a. b. I am attending (name of school) school and I am in the grade. grade. I am NOT attending school. The highest grade I have completed is

c. My plans concerning education or job training as follows:

6.

EMPLOYMENT:
a. I am employed and my occupation is: . I am employed by: (List name, address, and contact phone number for all employers) Employer # 1: Employer # 2:

I started work for Employer #1 (month / year):

I started work for Employer #2 (month / year):

b.

I am NOT currently employed. to (month / year) $ .

I last worked from (month / year)

My gross monthly earnings (before taxes or other deductions) were:

7.

PUBLIC ASSISTANCE:
a. b. c. I am not receiving welfare or TANF and I do not intend to apply for welfare of TANF. I am receiving welfare or TANF. Monthly amount received is: I have applied for or intend to apply for welfare or TANF. $

8.

AVERAGE MONTHLY INCOME (before taxes or other deductions)
a. Salary and Wages, including bonuses and overtime: b. Money received from adults (name and relationship to adults): Name, Relation Name, Relation c. Social Security benefits d. Other sources of income (specify source and amount) : $ $ $ $ $

TOTAL MONTHLY INCOME: $

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9.

I HAVE THE FOLLOWING ASSETS (things of value that I own):
a. Cash b. Checking Account(s) (total, if more than one) c. Savings Account(s) (total, if more than one) d. Stocks, Bonds e. Vehicle (Year, Make, and Model) f. Other (specify) g. Other (specify) h. Trust Fund $ $ $ $ $ $ $ $

TOTAL VALUE OF ASSETS: $ 10. I HAVE THE FOLLOWING EXPENSES:
a. Rent b. Food (groceries plus dining out) c. Clothing d. Utilities (phone plus electric, gas, cellular, water and sewer) e. Medical 1. insurance 2. doctor, dentist, hospital, urgent care 3. prescription medications Total Medical Expenses f. Transportation (public transit, bus and taxi) g. Vehicle 1. monthly payments 2. insurance 3. fuel/gasoline 4. service, maintenance and repair Total Vehicle Expenses h. Child Support i. Other (specify) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

TOTAL MONTHLY EXPENSES: $

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11.

AT LEAST ONE OF THE FOLLOWING IS INCLUDED WITH MY REQUEST (At least one box must be checked; you may check and attach more than one to support your request.) Attached is documentation that I have been living on my own for at least three consecutive months. Attached is a statement explaining why I believe that the home of my parent(s) and/or legal guardian(s) is not a health and/or safe environment. If you are currently with a legal guardian, be sure to. Attached is a notarized statement by one (or more) of my parent(s) and/or legal guardian(s) that contains written consent to my emancipation along with an explanation.

12.

Is there currently an "Order of Protection" between you and any parent or legal guardian? Yes No

If an "Order of Protection" has been issued, provide the name of the Court which issued this order: .

13. I REQUEST THAT THE COURT SCHEDULE A HEARING AND ENTER AN ORDER FOR MY EMANCIPATION. OATH OR AFFIRMATION OF MINOR PETITIONING FOR EMANCIPATION
I swear or affirm that I have read this document and that the contents are true and correct to the best of my knowledge, information, and belief, under penalty of law.

Signature of Minor

Date

Subscribed and sworn to or affirmed before me this date:

Clerk of Superior Court

OR Notary My Commission Expires: Deputy Clerk

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