Reset
FOR CLERK’S USE ONLY
Name of Person Filing:
________________________________________
Mailing Address:
________________________________________
City, State, Zip Code:
________________________________________
Day/Evening Telephone:
________________________________________
Attorney Bar Number (if applicable) ___________________________________
Representing:
Self (Without a Lawyer) or
Attorney for__________________________________
SUPERIOR COURT OF ARIZONA
MOHAVE COUNTY
In the Matter of:
Case Number: ___________________________
WAIVER BY PARENT OF
_________________________________________
NOTICE OF HEARING AND
APPEARANCE ON PETITION FOR
_________________________________________
TERMINATION OF PARENT-CHILD
RELATIONSHIP
_________________________________________
_________________________________________
Names of Minor Child(ren)
UNDER OATH or by AFFIRMATION:
INFORMATION FROM PARENT whose rights are to be terminated
1.
I, _______________________________________________, am the MOTHER or FATHER of the minor
child(ren) named below for whom a Petition has been filed requesting permanent termination (severance)
of my parental rights:
Full Name of Child
Date of Birth
___________________________________________________
___________________________
___________________________________________________
___________________________
___________________________________________________
___________________________
___________________________________________________
___________________________
2.
My complete name and address and date of birth is as follows:
Name:
________________________________________________________________________
Street Address: ________________________________________________________________________
City, State, Zip Code: ___________________________________________________________________
Telephone:
_____________________________________ Date of birth:
____________________
Page 1 of 2
2/24/2012