Voluntary Request For Order Of Paternity
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FOR CLERK’S USE ONLY
(a)
Name of Person Filing:
Mailing Address:
City, State, Zip Code:
Daytime Phone Number:
Evening Phone Number:
_______________________________
ATLAS Number (if applicable):
________________________________
Attorney Bar Number (if applicable):______________________________
Representing
Self
Petitioner
Respondent
SUPERIOR COURT OF ARIZONA
MOHAVE COUNTY
Case Number:
(Name of Petitioner)
VOLUNTARY REQUEST FOR ORDER
AND
OF PATERNITY (A.R.S. §25-812)
(Name of Respondent)
(b)
The parent(s) requests the Clerk to issue an Order establishing paternity for the following child(ren)
Full Name on Birth Certificate
Date of Birth
Place of Birth (City, County, State)
______________________________________
___________
____________________________________
______________________________________
___________
____________________________________
______________________________________
___________
____________________________________
The natural mother of the child(ren) was not married when the child(ren) were born or at any time throughout the ten
months immediately preceding such birth.
This request is based on: (Mark one box only)
(c)
Affidavit of Acknowledgment: By signing this, we agree and acknowledge that _________________________
is the natural father of the child(ren) named above.
Genetic Testing and Laboratory Affidavit: Attached is an affidavit from a certified laboratory indicating that
________________________ has not been excluded as the natural father of the child(ren) and we agree to be
bound by the results of this genetic test.
The changing of the child(ren’s) name is optional, not mandatory.
(d)
The parents request the Office of Vital Records amend the birth certificate(s) changing the child(ren)’s name(s)
from:
to:
______________________________________________
_________________________________________
______________________________________________
_________________________________________
______________________________________________
_________________________________________
Page 1 of 4
11/2/2006
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