In Re: Amendments to the Florida Supreme Court Approved Family Law Forms

Supreme Court of Florida
____________

No. SC15-44
____________

IN RE: AMENDMENTS TO THE FLORIDA SUPREME COURT
APPROVED FAMILY LAW FORMS.

[March 26, 2015]

PER CURIAM.

Pursuant to the procedures approved by this Court in Amendments to the

Florida Family Law Rules of Procedure & Family Law Forms, 810 So. 2d 1, 14

(Fla. 2000), this Court has internally reviewed the Florida Supreme Court

Approved Family Law Forms and has determined that amendments to the existing

forms are needed in light of the implementation of e-service and e-filing

procedures. Input on these issues was received from the Advisory Workgroup on

the Florida Supreme Court Approved Family Law Forms, which provided valuable

assistance. We have jurisdiction. See art. V, § 2(a), Fla. Const.

In general, the amendments to the forms add language explaining e-service

and e-filing to the instruction sections of the forms, add e-mail as method of
service to the certificate of service for forms not requiring personal service, and

add information about e-service and e-filing procedures to the General Instructions

for Self-Represented Litigants. Amendments are also made to several forms in

response to recent Court opinions or statutory changes. Other minor amendments

are made to update the “nonlawyer clause” and the certificate of service in a

number of forms.

The amended forms are hereby adopted as set forth in the appendix to this

opinion, fully engrossed. The amendments to the forms shall become effective

immediately and may be accessed and downloaded from the Florida State Court’s

website at www.flcourts.org/resources-and-services/court-improvement/problem-

solving-courts/family-courts/family-law-forms.stml. By adoption of the amended

forms, we express no opinion as to their correctness or applicability. We also

direct that the amended forms be published for comment. Interested persons shall

have sixty days from the date of this opinion to file comments with the Court.1

1. All comments must be filed with the Court on or before May 25, 2015, as
well as a separate request for oral argument if the person filing the comment
wishes to participate in oral argument, which may be scheduled in this case. If
filed by an attorney in good standing with The Florida Bar, the comment must be
electronically filed via the Portal in accordance with In re: Electronic Filing in the
Supreme Court of Florida via the Florida Courts E-Filing Portal, Fla. Admin. Order
No. AOSC13-7 (Feb 18, 2013). If filed by a non-lawyer or a lawyer not licensed
to practice in Florida, the comment must be electronically filed via e-mail in
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It is so ordered.

LABARGA, C.J., and PARIENTE, LEWIS, QUINCE, CANADY, POLSTON,
and PERRY, JJ., concur.

THE FILING OF A MOTION FOR REHEARING SHALL NOT ALTER THE
EFFECTIVE DATE OF THESE AMENDMENTS.

Original Proceedings – Florida Supreme Court Approved Family Law Forms

accordance with In re Mandatory Submission of Electronic Copies of Documents,
Fla. Admin. Order No. AOSC04-84 (Sept. 13, 2004). Electronically filed
documents must be submitted in Microsoft Word 97 or higher. Any person unable
to submit a comment electronically must mail or hand-deliver the originally signed
comment to the Florida Supreme Court, Office of the Clerk, 500 South Duval
Street, Tallahassee, Florida 32399-1927; no additional copies are required or will
be accepted.
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INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.901(b)(1),
PETITION FOR DISSOLUTION OF MARRIAGE WITH DEPENDENT OR
MINOR CHILD(REN) (03/15)

When should this form be used?

This form should be used when a husband or wife is filing for a dissolution of marriage and you and your
spouse have a dependent or minor child(ren) together or the wife is pregnant. You and/or your spouse
must have lived in Florida for at least 6 months before filing for a dissolution in Florida. You must file
this form if the following is true:

 You and your spouse have a dependent or minor child(ren) together or the wife is pregnant.

This form should be typed or printed in black ink. After completing this form, you should sign the form
before a notary public or deputy clerk. You should file the original with the clerk of the circuit court in
the county where you live and keep a copy for your records. Because you are filing the petition in this
proceeding, you may also be referred to as the petitioner and your spouse as the respondent.

IMPORTANT INFORMATION REGARDING E-FILING

The Florida Rules of Judicial Administration now require that all petitions, pleadings, and documents be
filed electronically except in certain circumstances. Self-represented litigants may file petitions or other
pleadings or documents electronically; however, they are not required to do so. If you choose to file
your pleadings or other documents electronically, you must do so in accordance with Florida Rule of
Judicial Administration 2.525, and you must follow the procedures of the judicial circuit in which you file.
The rules and procedures should be carefully read and followed.

What should I do next?

For your case to proceed, you must properly notify your spouse of the petition. If you know where he
or she lives, you should use personal service. If you absolutely do not know where he or she lives, you
may use constructive service. You may also be able to use constructive service if your spouse resides in
another state or country. However, if constructive service is used, other than granting a divorce, the
court may only grant limited relief, which cannot include either spousal support (alimony) or child
support. For more information on constructive service, see Notice of Action for Family Cases with
Minor Child(ren), Florida Supreme Court Approved Family Law Form 12.913(a)(2), and Affidavit of
Diligent Search and Inquiry, Florida Family Law Rules of Procedure Form 12.913(b). If your spouse is in
the military service of the United States, additional steps for service may be required. See, for example,
Memorandum for Certificate of Military Service, Florida Supreme Court Approved Family Law Form
12.912(a) and Affidavit of Military Service, Florida Supreme Court Approved Family Law Form
12.912(b). In sum, the law regarding constructive service and service on an individual in the military
service is very complex and you may wish to consult an attorney regarding these issues.

Instructions for Florida Supreme Court Approved Family Law Form 12.901(b)(1), Petition for
Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
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If personal service is used, your spouse has 20 days to answer after being served with your petition.
Your case will then generally proceed in one of the following three ways:

DEFAULT. If after 20 days, your spouse has not filed an answer, you may file a Motion for Default,
Florida Supreme Court Approved Family Law Form 12.922(a), with the clerk of court. Then, if you have
filed all of the required papers, you may call the clerk, family law intake staff, or judicial assistant to set
a final hearing. You must notify your spouse of the hearing by using a Notice of Hearing (General),
Florida Supreme Court Approved Family Law Form 12.923, or other appropriate notice of hearing form.

UNCONTESTED. If your spouse files an answer that agrees with everything in your petition or an
answer and waiver, and you have complied with mandatory disclosure and filed all of the required
papers, you may call the clerk, family law intake staff, or judicial assistant to set a final hearing. You
must notify your spouse of the hearing by using a Notice of Hearing (General), Florida Supreme Court
Approved Family Law Form 12.923, or other appropriate notice of hearing form.

CONTESTED... If your spouse files an answer or an answer and counterpetition, which disagrees with or
denies anything in your petition, and you are unable to settle the disputed issues, you should file a
Notice for Trial, Florida Supreme Court Approved Family Law Form 12.924, after you have complied with
mandatory disclosure and filed all of the required papers. Some circuits may require the completion of
mediation before a final hearing may be set. You should contact the clerk, family law intake staff, or
judicial assistant for instructions on how to set your case for trial (final hearing). If your spouse files an
answer and counterpetition, you should answer the counterpetition within 20 days using an Answer to
Counterpetition, Florida Supreme Court Approved Family Law Form 12.903(d).

Where can I look for more information?

Before proceeding, you should read General Information for Self-Represented Litigants found at the
beginning of these forms. The words that are in bold underline in these instructions are defined there.
For further information, see chapter 61, Florida Statutes.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

To serve and receive documents by e-mail, you must designate your e-mail addresses by using the
Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family Law Form
12.915, and you must provide your e-mail address on each form on which your signature appears.
Please CAREFULLY read the rules and instructions for: Certificate of Service (General), Florida Supreme

Instructions for Florida Supreme Court Approved Family Law Form 12.901(b)(1), Petition for
Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
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Court Approved Family Law Form 12.914; Designation of Current Mailing and E-mail Address, Florida
Supreme Court Approved Family Law Form 12.915; and Florida Rule of Judicial Administration 2.516.

Special notes...

If you do not have the money to pay the filing fee, you may obtain an Application for Determination of
Civil Indigent Status from the clerk, fill it out, and the clerk will determine whether you are eligible to
have filing fees deferred.

If you want to keep your address confidential because you are the victim of sexual battery, aggravated
child abuse, aggravated stalking, harassment, aggravated battery, or domestic violence, do not enter the
address, telephone, and fax information at the bottom of this form. Instead, file a Request for
Confidential Filing of Address, Florida Supreme Court Approved Family Law Form 12.980(h).

With this form, you must also file the following:

 Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida Supreme
Court Approved Family Law Form 12.902(d).
 Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e), if
you are asking that child support be ordered in the final judgment. (If you do not know your
spouse’s income, you may file this worksheet after his or her financial affidavit has been served
on you.)
 Affidavit of Corroborating Witness, Florida Supreme Court Approved Family Law Form 12.902(i)
OR photocopy of current Florida driver’s license, Florida identification card, or voter’s
registration card (issue date of copied document must be at least six months before date case is
actually filed with the clerk of the circuit court).
 Marital Settlement Agreement for Dissolution of Marriage with Dependent or Minor
Child(ren), Florida Supreme Court Approved Family Law Form 12.902(f)(1), if you and your
spouse have reached an agreement on any or all of the issues.
 Notice of Social Security Number, Florida Supreme Court Approved Family Law Form 12.902(j).
 Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or (c).
(This must be filed with the petition if the petitioner seeks to establish child support.
Otherwise, it must be filed within 45 days of service of the petition on the respondent.)
 Certificate of Compliance with Mandatory Disclosure, Florida Family Law Rules of Procedure
Form 12.932. (This must be filed within 45 days of service of the petition on the respondent, if
not filed at the time of the petition, unless you and your spouse have agreed not to exchange
these documents.)
 Parenting Plan, Florida Supreme Court Approved Family Law Form 12.995(a), (b), or (c). If the
parents have reached an agreement, a signed and notarized Parenting Plan should be attached.
If the parents have not reached an agreement, a proposed Parenting Plan may be filed.

Parenting Plan and Time-Sharing... If you and your spouse are unable to agree on parenting
arrangements and a time-sharing schedule, a judge will decide for you as part of establishing a Parenting
Plan. The judge will decide the parenting arrangements and time-sharing based on the child(ren)’s best
interests. Regardless of whether there is an agreement, the court reserves jurisdiction to modify issues
relating to the minor child(ren).

Instructions for Florida Supreme Court Approved Family Law Form 12.901(b)(1), Petition for
Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
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The judge may request a parenting plan recommendation or appoint a guardian ad litem in your case.
This means that a neutral person will review your situation and report to the judge concerning parenting
issues. The purpose of such intervention is to be sure that the best interests of the child(ren) is (are)
being served. For more information, you may consult section 61.13, Florida Statutes.

A parenting course must be completed prior to entry of the final judgment. You should contact the
clerk, family law intake staff, or judicial assistant about requirements for parenting courses where you
live.

Listed below are some terms with which you should become familiar before completing your petition. If
you do not fully understand any of the terms below or their implications, you should speak with an
attorney before going any further.

 Shared Parental Responsibility
 Sole Parental Responsibility
 Supervised Time-Sharing
 No contact
 Parenting Plan
 Parenting Plan Recommendation
 Time-Sharing Schedule

Child Support… The court may order one parent to pay child support to assist the other parent in
meeting the child(ren)’s material needs. Both parents are required to provide financial support, but
one parent may be ordered to pay a portion of his or her support for the child(ren) to the other parent.
Florida has adopted guidelines for determining the amount of child support to be paid. These guidelines
are based on the combined income of both parents and take into account the financial contributions of
both parents. You must file a Family Law Financial Affidavit, Florida Family Law Rules of Procedure
Form 12.902(b) or (c), and your spouse will be required to do the same. From your financial affidavits,
you should be able to calculate the amount of child support that should be paid using the Child Support
Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e). Because the child
support guidelines take several factors into consideration, change over time, and vary from state to
state, your child support obligation may be more or less than that of other people in seemingly similar
situations.

Alimony… Alimony may be awarded to a spouse if the judge finds that he or she has an actual need for
it and also finds that the other spouse has the ability to pay. If you want alimony, you must request it
in writing in the original petition or counterpetition. If you do not request alimony in writing before
the final hearing, it is waived (you may not request it later). You may request permanent alimony,
bridge-the-gap alimony, durational alimony, lump sum alimony, or rehabilitative alimony.

Marital/Nonmarital Assets and Liabilities… Florida law requires an equitable distribution of marital
assets and marital liabilities. “Equitable” does not necessarily mean “equal.” Many factors, including
child support, time-sharing, and alimony awards, may lead the court to make an unequal (but still
equitable) distribution of assets and liabilities. Nonmarital assets and nonmarital liabilities are those
assets and liabilities which the parties agree or the court determines belong to, or are the responsibility

Instructions for Florida Supreme Court Approved Family Law Form 12.901(b)(1), Petition for
Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
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of, only one of the parties. If the parties agree or the court finds an asset or liability to be nonmarital,
the judge will not consider it when distributing marital assets and liabilities.

Temporary Relief… If you need temporary relief regarding temporary use of assets, temporary
responsibility for liabilities, parental responsibility and time-sharing with child(ren), temporary child
support, or temporary alimony, you may file a Motion for Temporary Support and Time-Sharing with
Dependent or Minor Child(ren), Florida Supreme Court Approved Family Law Form 12.947(a). For more
information, see the instructions for that form.

Marital Settlement Agreement… If you and your spouse are able to reach an agreement on any or all of
the issues, you should file a Marital Settlement Agreement for Dissolution of Marriage with Dependent
or Minor Child(ren), Florida Supreme Court Approved Family Law Form 12.902(f)(1). Both of you must
sign this agreement before a notary public or deputy clerk. Any issues on which you are unable to
agree will be considered contested and settled by the judge at the final hearing.

Parenting Plan… In all cases involving minor or dependent child(ren), a Parenting Plan shall be approved
or established by the court. If you and your spouse have reached an agreement, you should file one of
the following: Parenting Plan, Florida Supreme Court Approved Family Law Form 12.995(a), Safety-
Focused Parenting Plan, Florida Supreme Court Approved Family Law Form 12.995(b), or
Relocation/Long-Distance Parenting Plan, Florida Supreme Court Approved Family Law Form 12.995(c),
which addresses the time-sharing schedule for the child(ren). If you have not reached an agreement, a
proposed Parenting Plan may be filed. If the parties are unable to agree, a Parenting Plan will be
established by the court.

Final Judgment Form… These family law forms contain a Final Judgment of Dissolution of Marriage
with Dependent or Minor Child(ren), Florida Supreme Court Approved Family Law Form 12.990(c)(1),
which the judge may use if your case is contested. If you and your spouse reach an agreement on all of
the issues, the judge may use a Final Judgment of Dissolution of Marriage with Dependent or Minor
Child(ren) (Uncontested), Florida Supreme Court Approved Family Law Form 12.990(b)(1). You should
check with the clerk, family law intake staff, or judicial assistant to see if you need to bring a final
judgment with you to the hearing. If so, you should type or print the heading, including the circuit,
county, case number, division, and the parties’ names, and leave the rest blank for the judge to
complete at your hearing or trial.

Nonlawyer… Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps
you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida
Family Law Rules of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill
out these forms also must put his or her name, address, and telephone number on the bottom of the
last page of every form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.901(b)(1), Petition for
Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
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IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
In re: The Marriage of:

______________________________,
Husband,

and

_______________________________,
Wife.

PETITION FOR DISSOLUTION OF MARRIAGE WITH
DEPENDENT OR MINOR CHILD(REN)

I, {full legal name} , the
{Choose only one}
_____ Husband _____ Wife, being sworn, certify that the following statements are true:

1. JURISDICTION/RESIDENCE
_____Husband _____ Wife _____ Both has (have) lived in Florida for at least 6 months before the filing
of this Petition for Dissolution of Marriage.
2. The husband _____ is or _____ is not a member of the military service.
The wife _____ is or _____ is not a member of the military service.
3. MARRIAGE HISTORY
Date of marriage: {month, day, year} ___________________
Date of separation: {month, day, year}_________________ (____Please indicate if approximate)
Place of marriage: {county, state, country} __________________________________________

4. DEPENDENT OR MINOR CHILD(REN)
{Choose all that apply}
a. _____ The wife is pregnant. Baby is due on: {date} _______________________
b. _____ The minor (under 18) child(ren) common to both parties are:

Name Birth date
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Florida Supreme Court Approved Family Law Form 12.901(b)(1), Petition for Dissolution of
Marriage with Dependent or Minor Child(ren) (03/15)
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_____________________________________________________________________________________
_____________________________________________________________________________________
___________________________________________

c._____ The minor child(ren) born or conceived during the marriage who are not common to both
parties are:
Name Birth date
_____________________________________________________________________________________
_______________________________________________________________________
The birth father(s) of the above minor child(ren) is (are) {name and address} ________________
______________________________________________________________________________

d._____The child(ren) common to both parties who are 18 or older but who are dependent upon the
parties due to a mental or physical disability are:
Name Birth date
_____________________________________________________________________________________
_______________________________________________________________________

5. A completed Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form
12.902(b) or (c) {choose only one} _____ is filed with this petition or _____ will be timely filed.

6. A completed Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida
Supreme Court Approved Family Law Form 12.902(d), is filed with this petition. (You must
complete and attach this form in a dissolution of marriage with minor child(ren)).

7. A completed Notice of Social Security Number, Florida Supreme Court Approved Family Law
Form 12.902(j), is filed with this petition.

8. This petition for dissolution of marriage should be granted because:
{Choose only one}
a. _____ The marriage is irretrievably broken.
b. _____ One of the parties has been adjudged mentally incapacitated for a period of 3 years
prior to the filing of this petition. A copy of the Judgment of Incapacity is attached.

SECTION I. MARITAL ASSETS AND LIABILITIES

1. _____ There are no marital assets or liabilities.

2. _____ There are marital assets or liabilities. All marital and nonmarital assets and liabilities are
(or will be) listed in the financial affidavits, Florida Family Law Rules of Procedure Form
12.902(b) or (c), filed in this case.
{Indicate all that apply}
a._____ All marital assets and liabilities have been divided by a written agreement between the parties,
which is attached, to be incorporated into the final judgment of dissolution of marriage. (The parties
Florida Supreme Court Approved Family Law Form 12.901(b)(1), Petition for Dissolution of
Marriage with Dependent or Minor Child(ren) (03/15)
- 10 -
may use Marital Settlement Agreement for Dissolution of Marriage with Dependent or Minor Child(ren),
Florida Supreme Court Approved Family Law Form 12.902(f)(1).
b._____ The Court should determine how the assets and liabilities of this marriage are to be distributed,
under section 61.075, Florida Statutes.

c._____ Husband _____Wife should be awarded an interest in the other spouse’s property because:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

SECTION II. SPOUSAL SUPPORT (ALIMONY)

1. _____ Husband _____Wife forever gives up his/her right to spousal support (alimony) from
the other spouse.

2. _____ Husband _____Wife requests that the Court order the other spouse to pay the following
spousal support (alimony) and claims that he or she has an actual need for the support that he
or she is requesting and that the other spouse has the ability to pay that support. Spousal
support (alimony) is requested in the amount of $________ every _____ week _____ other
week _____ month, beginning {date} ___________________ and continuing until {date or
event} _____________________________________________________________________.
{Explain why the Court should order ____Husband ____Wife to pay, and any specific request(s) for type
of alimony (temporary, permanent, bridge-the-gap, durational, rehabilitative, and/or lump sum}:

3. _____Other provisions relating to alimony, including any tax treatment and consequences:
_____________________________________________________________________________________
_____________________________________________________________________________________
________________________________________________________________.

4. _____ Husband _____ Wife requests life insurance on the other spouse’s life, provided by that
spouse, to secure such support.

SECTION III. PARENTING PLAN ESTABLISHING PARENTAL RESPONSIBILITY AND TIME-SHARING

1. The minor child(ren) currently reside(s) with _____ Mother _____ Father _____ Other: {explain}

2. Parental Responsibility. It is in the child(ren)’s best interests that parental responsibility be:
{Choose only one}
a. ____ shared by both Father and Mother.
Florida Supreme Court Approved Family Law Form 12.901(b)(1), Petition for Dissolution of
Marriage with Dependent or Minor Child(ren) (03/15)
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b. ____ awarded solely to _____ Father _____ Mother. Shared parental responsibility would
be detrimental to the child(ren) because:_________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.

3. Parenting Plan and Time-Sharing.
It is in the best interests of the child(ren) that the family be ordered to comply with a Parenting
Plan that _____ includes _____ does not include parental time-sharing with the child(ren). The
Petitioner states that it is in the best interests of the child(ren) that:
{Choose only one}
a.____ The attached proposed Parenting Plan should be adopted by the court. The parties
{Choose only one} _____ have _____ have not agreed to the Parenting Plan.

b.____ The court should establish a Parenting Plan with the following provisions:
____ No time-sharing for the _____ Father____ Mother.
____ Limited time-sharing with the ____Father____Mother.
____ Supervised Time-Sharing for the _____ Father_____ Mother.
____ Supervised or third-party exchange of the child(ren).
____ Time-Sharing Schedule as follows:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

4. Explain why this request is in the best interests of the child(ren):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.

SECTION IV. CHILD SUPPORT
{Choose all that apply}
1. ____ Husband ____Wife requests that the Court award child support as determined by Florida’s
child support guidelines, section 61.30, Florida Statutes. A completed Child Support Guidelines
Worksheet, Florida Family Law Rules of Procedure Form 12.902(e), _____ is, or _____ will be
filed. Such support should be ordered retroactive to:
a. ____ the date of separation {date} _________________________ .
b. ____ the date of the filing of this petition.
c. ____ other {date} ____________ {explain} ___________________________________.

2. ____ Husband ____Wife requests that the Court award child support to be paid beyond the age
of 18 years because:
a.____ the following child(ren) {name(s)}
is (are) dependent because of a mental or physical incapacity which began before the age of 18.
{explain}
.

Florida Supreme Court Approved Family Law Form 12.901(b)(1), Petition for Dissolution of
Marriage with Dependent or Minor Child(ren) (03/15)
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b.____ the following child(ren) {name(s)}________________________is (are) dependent in fact, is (are)
in high school, and are between the ages of 18 and 19; said child(ren) is (are) performing in good faith
with reasonable expectation of graduation before the age of 19.

3. _____Husband _____ Wife requests that the Court award a child support amount that is more
than or less than Florida’s child support guidelines and understands that a Motion to Deviate
from Child Support Guidelines, Florida Supreme Court Approved Family Law Form 12.943, must
be filed before the Court will consider this request.

4. _____Husband _____Wife requests that medical/dental insurance for the minor child(ren) be
provided by:
{Choose only one}
a. ____ Husband.
b. ____ Wife.

5. ____Husband ____ Wife requests that uninsured medical/dental expenses for the child(ren) be
paid:
{Choose only one}
a. ____by Husband.
b. ____by Wife.
c. ____by Husband and Wife equally [each pay one-half].
d. ____according to the percentages in the Child Support Guidelines Worksheet, Florida Family
Law Rules of Procedure Form 12.902(e).
e. ____Other {explain}: __________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

6. _____Husband ____Wife requests that life insurance to secure child support be provided by the
other spouse.

SECTION V. OTHER
1. ____ Wife requests to be known by her former name, which was {full legal name}:
_____________________________________________________________________ .

SECTION VI. REQUEST (This section summarizes what you are asking the Court to include in the final
judgment of dissolution of marriage.)
____Husband ___Wife requests that the Court enter an order dissolving the marriage and:
{Indicate all that apply}
1. ____distributing marital assets and liabilities as requested in Section I of this petition;
Florida Supreme Court Approved Family Law Form 12.901(b)(1), Petition for Dissolution of
Marriage with Dependent or Minor Child(ren) (03/15)
- 13 -
2. ____awarding spousal support (alimony) as requested in Section II of this petition;
3. ____ adopting or establishing a Parenting Plan containing provisions for parental responsibility
and time-sharing for the dependent or minor child(ren) common to both parties, as requested in
Section III of this petition;
4. ____establishing child support for the dependent or minor child(ren) common to both parties,
as requested in Section IV of this petition;
5. ____restoring Wife’s former name as requested in Section V of this petition;
6. ____awarding other relief as requested in Section V of this petition; and any other terms the
Court deems necessary.

I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
petition and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.

Dated_________________________ _____________________________________________
Signature of _____ HUSBAND _____WIFE

Printed Name:
Address: ______________________________________
City, State, Zip: _________________________________
Telephone Number: _____________________________
Fax Number: __________________________________________
Designated E-mail Address(es): ____________________
_____________________________________________

STATE OF FLORIDA
COUNTY OF ____________________

Sworn to or affirmed and signed before me on __________ by _________________________________.

_____________________________________________
NOTARY PUBLIC or DEPUTY CLERK

_____________________________________________
{Print, type, or stamp commissioned name of notary or deputy clerk.}
____ Personally known
____ Produced identification
Type of identification produced ________________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Husband ( ) Wife
This form was completed with the assistance of:
{name of individual}_______________________________________________________________,
{name of business} ________________________________________________________________,
Florida Supreme Court Approved Family Law Form 12.901(b)(1), Petition for Dissolution of
Marriage with Dependent or Minor Child(ren) (03/15)
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{address} ________________________________________________________________________,
{city}________________{state}_____, {zip code}________, {telephone number} _______________.

Florida Supreme Court Approved Family Law Form 12.901(b)(1), Petition for Dissolution of
Marriage with Dependent or Minor Child(ren) (03/15)
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INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.901(b)(2)
PETITION FOR DISSOLUTION OF MARRIAGE WITH PROPERTY BUT NO
DEPENDENT OR MINOR CHILD(REN) (03/15)

When should this form be used?

This form may be used when a husband or wife is filing for a dissolution of marriage, and the husband
and wife have marital assets and/or marital liabilities but they do not have any dependent children nor
is the wife pregnant. You and/or your spouse must have lived in Florida for at least 6 months before
filing for a dissolution in Florida. If you and your spouse agree on all issues and both can attend the
hearing, you may want to file a Petition for Simplified Dissolution of Marriage, Florida Family Law Rules
of Procedure Form 12.901(a). However, you cannot file for a simplified dissolution of marriage if any of
the following are true:

 You disagree about property, debts, or other matters and wish to have a judge settle them for you.
 Either you or your spouse is seeking support (alimony).
 You would like to ask questions and get documents concerning your spouse’s income, expenses,
assets, debts, or other matters before having a trial or settlement.
 You would like to reserve your rights to have any matters reconsidered or appeal the judge’s
decision.

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?
For your case to proceed, you must properly notify your spouse of the petition. If you know where he
or she lives, you should use personal service. If you absolutely do not know where he or she lives, you
may use constructive service. You may also be able to use constructive service if your spouse resides in
another state or country. However, if constructive service is used, other than granting a divorce, the
court may only grant limited relief which cannot include spousal support (alimony). For more

Instructions for Florida Supreme Court Approved Family Law Form 12.901(b)(2), Petition for
Dissolution of Marriage with Property but No Dependent or Minor Child(ren) (03/15)
- 16 -
information on constructive service, see Notice of Action for Dissolution of Marriage (No Child or
Financial Support), Florida Supreme Court Approved Family Law Form 12.913(a)(1), and Affidavit of
Diligent Search and Inquiry, Florida Family Law Rules of Procedure Form 12.913(b). If your spouse is in
the military service of the United States, additional steps for service may be required. See, for example,
Memorandum for Certificate of Military Service, Florida Supreme Court Approved Family Law Form
12.912(a) and Affidavit of Military Service, Florida Supreme Court Approved Family Law Form
12.912(b). In sum, the law regarding constructive service and service on an individual in the military
service is very complex and you may wish to consult an attorney regarding these issues.

If personal service is used, your spouse has 20 days to answer after being served with your petition.
Your case will then generally proceed in one of the following three ways:

DEFAULT... If after 20 days, your spouse has not filed an answer, you may file a Motion for Default,
Florida Supreme Court Approved Family Law Form 12.922(a), with the clerk of court. Then, if you have
filed all of the required papers, you may call the clerk, family law intake staff, or judicial assistant to set
a final hearing. You must notify your spouse of the hearing by using a Notice of Hearing (General),
Florida Supreme Court Approved Family Law Form 12.923, or other appropriate notice of hearing form.
UNCONTESTED... If your spouse files an answer that agrees with everything in your petition or an
answer and waiver, and you have complied with mandatory disclosure and filed all of the required
papers, you may call the clerk, family law intake staff, or judicial assistant to set a final hearing. You
must notify your spouse of the hearing by using a Notice of Hearing (General), Florida Supreme Court
Approved Family Law Form 12.923, or other appropriate notice of hearing form.

Where can I look for more information?

Before proceeding, you should read “General Information for Self-Represented Litigants” found at the
beginning of these forms. The words that are in bold underline in these instructions are defined there.
For further information, see chapter 61, Florida Statutes.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Special notes...

With this form, you must also file the following:

 Affidavit of Corroborating Witness, Florida Supreme Court Approved Family Law Form 12.902(i) OR
photocopy of current Florida driver’s license, Florida identification card, or voter’s registration card
(issue date of copied document must be at least six months before date case is actually filed with
the clerk of the circuit court).
 Marital Settlement Agreement for Dissolution of Marriage with No Dependent or Minor
Child(ren), Florida Supreme Court Approved Family Law Form 12.902(f)(2), if you and your spouse
have reached an agreement on any or all of the issues.
 Notice of Social Security Number, Florida Supreme Court Approved Family Law Form 12.902(j).
 Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or (c). (This
must be filed within 45 days of service of the petition on the respondent, if not filed at the time of
the petition.)
 Certificate of Compliance with Mandatory Disclosure, Florida Family Law Rules of Procedure Form
12.932. (This must be filed within 45 days of service of the petition on the respondent, if not filed at
the time of the petition, unless you and your spouse have agreed not to exchange these
documents.)

Instructions for Florida Supreme Court Approved Family Law Form 12.901(b)(2), Petition for
Dissolution of Marriage with Property but No Dependent or Minor Child(ren) (03/15)
- 18 -
Alimony... Alimony may be awarded to a spouse if the judge finds that he or she has an actual need for
it and also finds that the other spouse has the ability to pay. If you want alimony, you must request it
in writing in the original petition or counterpetition. If you do not request alimony in writing before
the final hearing, it is waived (you may not request it later). You may request permanent alimony,
bridge-the-gap alimony, durational alimony, lump sum alimony, or rehabilitative alimony.

Marital/Nonmarital Assets and Liabilities... Florida law requires an equitable distribution of marital
assets and marital liabilities. “Equitable” does not necessarily mean “equal.” Many factors, including
alimony awards, may lead the court to make an unequal (but still equitable) distribution of assets and
liabilities. Nonmarital assets and nonmarital liabilities are those assets and liabilities which the parties
agree or the court determines belong to, or are the responsibility of, only one of the parties. If the
parties agree or the court finds an asset or liability to be nonmarital, the judge will not consider it when
distributing marital assets and liabilities.

Temporary Relief... If you need temporary relief regarding temporary use of assets, temporary
responsibility for liabilities, or temporary alimony, you may file a Motion for Temporary Support with
No Dependent or Minor Child(ren), Florida Supreme Court Approved Family Law Form 12.947(c). For
more information, see the instructions for that form.

Marital Settlement Agreement... If you and your spouse are able to reach an agreement on any or all of
the issues, you should file a Marital Settlement Agreement for Dissolution of Marriage with Property
But No Dependent or Minor Child(ren), Florida Supreme Court Approved Family Law Form 12.902(f)(2).
Both husband and wife must sign this agreement before a notary public or deputy clerk. Any issues on
which you are unable to agree will be considered contested and settled by the judge at the final hearing.

Final Judgment Form... These family law forms contain a Final Judgment of Dissolution of Marriage
with Property but No Dependent or Minor Child(ren), Florida Supreme Court Approved Family Law
Form 12.990(c)(2), which the judge may use if your case is contested. If you and your spouse reach an
agreement on all of the issues, the judge may use a Final Judgment of Dissolution of Marriage with
Property but No Dependent or Minor Child(ren) (Uncontested), Florida Supreme Court Approved
Family Law Form 12.990(b)(2). You should check with the clerk, family law intake staff, or judicial
assistant to see if you need to bring a final judgment with you to the hearing. If so, you should type or
print the heading, including the circuit, county, case number, division, and the parties’ names, and leave
the rest blank for the judge to complete at your hearing or trial.

Nonlawyer... Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps
you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida
Family Law Rules of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill
out these forms also must put his or her name, address, and telephone number on the bottom of the
last page of every form he or she helps you complete.

Case No: ________________________
In re: the Marriage of: Division: ________________________

_________________________________,
Husband,
and

_________________________________,
Wife.

PETITION FOR DISSOLUTION OF MARRIAGE WITH PROPERTY
BUT NO DEPENDENT OR MINOR CHILD(REN)

I, {full legal name} ______________________________________________________, the
[Choose one only] ( ) Husband ( ) Wife, being sworn, certify that the following statements are
true:

1. JURISDICTION/RESIDENCE
_____ Husband _____ Wife _____ Both has (have) lived in Florida for at least 6 months before the filing
of this Petition for Dissolution of Marriage.

2. The husband _____ is or _____ is not a member of the military service.
The wife _____ is or _____ is not a member of the military service.

3. MARRIAGE HISTORY
Date of marriage: {month, day, year} _________________________
Date of separation: {month, day, year} ___________________ {Please indicate if approximate}
Place of marriage: {county, state, country} ____________________________________________

4. THERE ARE NO MINOR (under 18) OR DEPENDENT CHILD(REN) COMMON TO BOTH PARTIES AND
THE WIFE IS NOT PREGNANT.

5. A completed Notice of Social Security Number, Florida Supreme Court Approved Family Law Form
12.902(j), is filed with this petition.

6. THIS PETITION FOR DISSOLUTION OF MARRIAGE SHOULD BE GRANTED BECAUSE:

a. _____ The marriage is irretrievably broken.
OR

Florida Supreme Court Approved Family Law Form 12.901(b)(2), Petition for Dissolution of
Marriage with Property but No Dependent or Minor Child(ren) (03/15)
- 20 -
b. _____ One of the parties has been adjudged mentally incapacitated for a period of 3 years
before the filing of this petition. A copy of the Judgment of Incapacity is attached.

SECTION I. MARITAL ASSETS AND LIABILITIES

1. ____ There are no marital assets or liabilities.

2. ____ There are marital assets or liabilities. All marital and nonmarital assets and liabilities are (or
will be) listed in the financial affidavits, Florida Family Law Rules of Procedure Form 12.902(b) or (c),
to be filed in this case.
[Indicate all that apply]
a. ____ All marital assets and debts have been divided by a written agreement between the
parties, which is attached to be incorporated into the final judgment of dissolution of marriage.
(The parties may use Marital Settlement Agreement for Simplified Dissolution of Marriage,
Florida Family Law Rules of Procedure Form 12.902(f)(3) or Marital Settlement Agreement for
Dissolution of Marriage with No Dependent or Minor Child(ren), Florida Supreme Court
Approved Family Law Form 12.902(f)(2)).

b. ____ The Court should determine how the assets and liabilities of this marriage are to be
distributed, under section 61.075, Florida Statutes.

c. ____Husband _____Wife should be awarded an interest in _____ the other spouse’s property
because:_____________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________.

SECTION II. SPOUSAL SUPPORT (ALIMONY)

1. ____ Husband ____ Wife forever gives up his/her right to spousal support (alimony) from the
other spouse.

2. ____ Husband ____Wife requests that the Court order the other spouse to pay the following spousal
support (alimony) and claims that he or she has an actual need for the support that he or she is
requesting and that the other spouse has the ability to pay that support. Spousal support
(alimony) is requested in the amount of $ _________ every ( ) week ( ) other week ( ) month,
beginning {date} ____________________________________and continuing until {date or event}
_________________________________________________________________________________.
{Explain why the Court should order _____Husband _____Wife to pay and any specific request(s) for type
of alimony (temporary, permanent, bridge-the-gap, durational, rehabilitative, and/or lump sum}:
_________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Florida Supreme Court Approved Family Law Form 12.901(b)(2), Petition for Dissolution of
Marriage with Property but No Dependent or Minor Child(ren) (03/15)
- 21 -
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________.
3._____Other provisions relating to alimony including any tax treatment and consequences:
____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________

4._____ Husband _____Wife requests life insurance on the other spouse’s life, provided by that spouse,
to secure such support.

SECTION III. OTHER
1. _____Wife requests to be known by her former name, which was {full legal name}
________________________________________________________________________________.

2. Other relief {specify}: _______________________________________________________________.
__________________________________________________________________________________
__________________________________________________________________________________

SECTION IV. REQUEST
(This section summarizes what you are asking the Court to include in the final judgment of dissolution
of marriage.)
_____Husband _____Wife requests that the Court enter an order dissolving the marriage and:
[Indicate all that apply]
1. ____ distributing marital assets and liabilities as requested in Section I of this petition;

2. ____ awarding spousal support (alimony) as requested in Section II of this petition;

3. ____ restoring Wife’s former name as requested in Section III of this petition;

4. ____ awarding other relief as requested in Section III of this petition; and any other terms the Court
deems necessary.

Florida Supreme Court Approved Family Law Form 12.901(b)(2), Petition for Dissolution of
Marriage with Property but No Dependent or Minor Child(ren) (03/15)
- 22 -
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
petition and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.

Dated: ______________________ _____________________________________________
Signature of _____ HUSBAND _____ WIFE
Printed Name: _________________________________
Address: ______________________________________
City, State, Zip: _________________________________
Telephone Number: _____________________________
Fax Number: __________________________________
Designated E-mail Address(es): ____________________

STATE OF FLORIDA
COUNTY OF ____________________

Sworn to or affirmed and signed before me on ____________ by _______________________________.

_____________________________________________
NOTARY PUBLIC or DEPUTY CLERK

_____________________________________________
{Print, type, or stamp commissioned name of notary or deputy clerk.}
____ Personally known
____ Produced identification
____ Type of identification produced ________________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Husband ( ) Wife
This form was completed with the assistance of:
{name of individual} ___________________________________________________________________,
{name of business} ____________________________________________________________________,
{address} ____________________________________________________________________________,
{city} _______________,{state} _____{zip code}___________, {telephone number} _________________.

Florida Supreme Court Approved Family Law Form 12.901(b)(2), Petition for Dissolution of
Marriage with Property but No Dependent or Minor Child(ren) (03/15)
- 23 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.901(b)(3)
PETITION FOR DISSOLUTION OF MARRIAGE WITH
NO DEPENDENT OR MINOR CHILD(REN) OR PROPERTY
(03/15)

When should this form be used?

This form may be used when a husband or wife is filing for a dissolution of marriage, and the husband
and wife have no marital assets and/or marital liabilities and they do not have any dependent children
nor is the wife pregnant. You and/or your spouse must have lived in Florida for at least 6 months before
filing for a dissolution in Florida. If you and your spouse agree on all issues and both can attend the
hearing, you may want to file a Petition for Simplified Dissolution of Marriage, Florida Family Law Rules
of Procedure Form 12.901(a). However, you may use this form if all of the following are true:

 You have no marital assets or marital debts.
 Neither you nor your spouse is seeking support (alimony).

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?

Instructions to Florida Supreme Court Approved Law Form 12.901(b)(3), Petition for Dissolution
of Marriage with No Dependent or Minor Child(ren) or Property (03/15)
- 24 -
the military service of the United States, additional steps for service may be required. See, for example,
Memorandum for Certificate of Military Service, Florida Supreme Court Approved Family Law Form
12.912(a) and Affidavit of Military Service, Florida Supreme Court Approved Family Law Form
12.912(b). In sum, the law regarding constructive service and service on an individual in the military
service is very complex and you may wish to consult an attorney regarding these issues.

If personal service is used, your spouse has 20 days to answer after being served with your petition.
Your case will then generally proceed in one of the following three ways:

UNCONTESTED... If your spouse files an answer that agrees with everything in your petition or an
answer and waiver, and you have complied with mandatory disclosure and filed all of the required
papers, you may call the clerk, family law intake staff, or judicial assistant to set a final hearing. You
must notify your spouse of the hearing by using a Notice of Hearing (General), Florida Supreme Court
Approved Family Law Form 12.923, or other appropriate notice of hearing form.

CONTESTED... If your spouse files an answer or an answer and counterpetition, which disagrees with or
denies anything in your petition, and you are unable to settle the disputed issues, you should file a
Notice for Trial, Florida Supreme Court Approved Family Law Form 12.924, after you have complied with
mandatory disclosure and filed all of the required papers. Some circuits may require the completion of
mediation before a final hearing may be set. You should contact the clerk, family law intake staff, or
judicial assistant for instructions on how to set your case for trial (final hearing). If the your spouse files
an answer and counterpetition, you should answer the counterpetition within 20 days using an Answer
to Counterpetition, Florida Supreme Court Approved Family Law Form 12.903(d).

Where can I look for more information?

Before proceeding, you should read “General Information for Self-Represented Litigants” found at the
beginning of these forms. The words that are in “bold underline” in these instructions are defined
there. For further information, see chapter 61, Florida Statutes.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions to Florida Supreme Court Approved Law Form 12.901(b)(3), Petition for Dissolution
of Marriage with No Dependent or Minor Child(ren) or Property (03/15)
- 25 -
SELF-REPRESENTED LITIGANTS MAY SERVE DOCUMENTS BY E-MAIL; HOWEVER, THEY ARE NOT
REQUIRED TO DO SO. If a self-represented litigant elects to serve and receive documents by e-mail, the
procedures must always be followed once the initial election is made.

Special notes...

With this form, you must also file the following:

 Affidavit of Corroborating Witness, Florida Supreme Court Approved Family Law Form 12.902(i) OR
photocopy of current Florida driver’s license, Florida identification card, or voter’s registration card
(issue date of copied document must be at least six months before date case is actually filed with
the clerk of the circuit court).
 Notice of Social Security Number, Florida Supreme Court Approved Family Law Form 12.902(j).
 Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or (c). (This
must be filed within 45 days of service of the petition on the respondent, if not filed at the time of
the petition.)
 Certificate of Compliance with Mandatory Disclosure, Florida Family Law Rules of Procedure Form
12.932. (This must be filed within 45 days of service of the petition on the respondent, if not filed at
the time of the petition, unless you and your spouse have agreed not to exchange these
documents.)

Final Judgment Form... These family law forms contain a Final Judgment of Dissolution of Marriage
with No Property or Minor Child(ren) (Uncontested), Florida Supreme Court Approved Family Law Form
12.990(b)(3). You should check with the clerk, family law intake staff, or judicial assistant to see if you
need to bring a final judgment with you to the hearing. If so, you should type or print the heading,
including the circuit, county, case number, division, and the parties’ names, and leave the rest blank for
the judge to complete at your hearing or trial.

Instructions to Florida Supreme Court Approved Law Form 12.901(b)(3), Petition for Dissolution
of Marriage with No Dependent or Minor Child(ren) or Property (03/15)
- 26 -
Nonlawyer... Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps
you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida
Family Law Rules of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill
out these forms also must put his or her name, address, and telephone number on the bottom of the
last page of every form he or she helps you complete.

Instructions to Florida Supreme Court Approved Law Form 12.901(b)(3), Petition for Dissolution
of Marriage with No Dependent or Minor Child(ren) or Property (03/15)
- 27 -
IN THE CIRCUIT COURT OF THE _____________________ JUDICIAL CIRCUIT,
IN AND FOR ______________________________ COUNTY, FLORIDA

In re: the Marriage of: Case No: ________________________
Division: ________________________

_________________________________,
Husband,
and

_________________________________,
Wife.

PETITION FOR DISSOLUTION OF MARRIAGE WITH NO DEPENDENT
OR MINOR CHILD(REN) OR PROPERTY

I, {full legal name} ______________________________________________________, the
[Choose only one] ____ Husband ____ Wife, being sworn, certify that the following statements are true:

1. JURISDICTION/RESIDENCE
_____ Husband _____ Wife _____ Both has (have) lived in Florida for at least 6 months before the filing
of this Petition for Dissolution of Marriage.

2. The husband _____ is or _____ is not a member of the military service.
The wife _____ is or _____ is not a member of the military service.

3. MARRIAGE HISTORY
Date of marriage: {month, day, year} ________________________________________________
Place of marriage: {county, state, country}_____________________________________________

4. THERE ARE NO MINOR (under 18) OR DEPENDENT CHILD(REN) COMMON TO BOTH PARTIES AND
THE WIFE IS NOT PREGNANT.

5. A completed Notice of Social Security Number, Florida Supreme Court Approved Family Law Form
12.902(j), is filed with this petition.

6. THIS PETITION FOR DISSOLUTION OF MARRIAGE SHOULD BE GRANTED BECAUSE:

a. _____ The marriage is irretrievably broken.
OR
b. _____ One of the parties has been adjudged mentally incapacitated for a period of 3 years
before the filing of this petition. A copy of the Judgment of Incapacity is attached.

7. THERE ARE NO MARITAL ASSETS OR LIABILITIES.

Florida Supreme Court Approved Law Form 12.901(b)(3), Petition for Dissolution of Marriage
with No Dependent or Minor Child(ren) or Property (03/15)
- 28 -
8. _____HUSBAND _____ WIFE FOREVER GIVES UP HIS/HER RIGHTS TO SPOUSAL SUPPORT
(ALIMONY) FROM THE OTHER SPOUSE.

9. _____Wife requests to be known by her former name, which was {full legal name}
______________________________________________________________________________.

10. Other relief {specify}: ________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________.

REQUEST
(This section summarizes what you are asking the Court to include in the final judgment of dissolution of
marriage.)
_____Husband _____Wife requests that the Court enter an order dissolving the marriage and:
[Indicate all that apply]
1. ____ restoring Wife’s former name as specified in paragraph 9 of this petition;

2. ____ awarding other relief as specified in paragraph 10 of this petition; and any other terms the
Court deems necessary.

STATE OF FLORIDA
COUNTY OF ____________________

Sworn to or affirmed and signed before me on ____________ by _______________________________.

_____________________________________________
NOTARY PUBLIC or DEPUTY CLERK
Florida Supreme Court Approved Law Form 12.901(b)(3), Petition for Dissolution of Marriage
with No Dependent or Minor Child(ren) or Property (03/15)
- 29 -
____________________________________________
{Print, type, or stamp commissioned name of notary or deputy clerk.}
_____ Personally known
_____ Produced identification
_____ Type of identification produced ________________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Husband ( ) Wife
This form was completed with the assistance of:
{name of individual} _________________________________________________________________,
{name of business} __________________________________________________________________,
{address} __________________________________________________________________________,
{city} ______________,{state} _____,{zip code}___________,{telephone number} ________________.

Florida Supreme Court Approved Law Form 12.901(b)(3), Petition for Dissolution of Marriage
with No Dependent or Minor Child(ren) or Property (03/15)
- 30 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.902(d)
UNIFORM CHILD CUSTODY JURISDICTION AND ENFORCEMENT ACT
(UCCJEA) AFFIDAVIT (03/15)

When should this form be used?

This form should be used in any case involving custody of, visitation with, or time-sharing with any minor
child(ren). This affidavit is required even if the custody of, visitation, or time-sharing with the minor
child(ren) are not in dispute.

This form should be typed or printed in black ink. After completing this form, you should sign the form
before a notary public or deputy clerk. You should then file the original with the clerk of the circuit
court in the county where the petition was filed and keep a copy for your records.

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?

A copy of this form must be mailed, e-mailed, or hand delivered to the other party in your case, if it is
not served on him or her with your initial papers.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions for Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child
Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit (03/15)
- 31 -
SELF-REPRESENTED LITIGANTS MAY SERVE DOCUMENTS BY E-MAIL; HOWEVER, THEY ARE NOT
REQUIRED TO DO SO. If a self-represented litigant elects to serve and receive documents by e-mail, the
procedures must always be followed once the initial election is made.
To serve and receive documents by e-mail, you must designate your e-mail addresses by using the
Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family Law Form
12.915, and you must provide your e-mail address on each form on which your signature appears.
Please CAREFULLY read the rules and instructions for: Certificate of Service (General), Florida Supreme
Court Approved Family Law Form 12.914; Designation of Current Mailing and E-mail Address, Florida
Supreme Court Approved Family Law Form 12.915; and Florida Rule of Judicial Administration 2.516.

Where can I look for more information?

Special notes...

Chapter 2008-61, Laws of Florida, effective October 1, 2008, eliminated such terms as custodial parent,
noncustodial parent, primary residential parent, secondary residential parent, and visitation from
Chapter 61, Florida Statutes. Instead, parents are to develop a Parenting Plan that includes, among
other things, their time-sharing schedule with the minor child(ren). If the parents cannot agree, a
parenting plan will be established by the Court. However, because the UCCJEA uses the terms custody
and visitation, they are included in this form.

If you are the petitioner in an injunction for protection against domestic violence case and you have filed
a Request for Confidential Filing of Address, Florida Supreme Court Approved Family Law Form
12.980(h), you should write confidential in any space on this form that would require you to write the
address where you are currently living.

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child
Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit (03/15)
- 32 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
,
Petitioner,

and

,
Respondent.

UNIFORM CHILD CUSTODY JURISDICTION AND ENFORCEMENT ACT
(UCCJEA) AFFIDAVIT

I, {full legal name} ____________, being sworn, certify that the following
statements are true:

1. The number of minor child(ren) subject to this proceeding is . The name, place of
birth, birth date, and sex of each child; the present address, periods of residence, and places where
each child has lived within the past five (5) years; and the name, present address, and relationship
to the child of each person with whom the child has lived during that time are:

THE FOLLOWING INFORMATION IS TRUE ABOUT CHILD # 1 :

Child’s Full Legal Name:
Place of Birth: Date of Birth: Sex:

Child’s Residence for the past 5 years:
Dates Address (including city and Name and present address of Relationship
(From/To) state) where child lived person child lived with to child

/present*

____/____

Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody
Jurisdiction and Enforcement Act (UCCJEA) Affidavit (03/15)
- 33 -
____/____

____/____
* If you are the petitioner in an injunction for protection against domestic violence case and you have
filed a Request for Confidential Filing of Address, Florida Supreme Court Approved Family Law Form
12.980(h), you should write confidential in any space on this form that would require you to enter the
address where you are currently living.

THE FOLLOWING INFORMATION IS TRUE ABOUT CHILD # :

Child’s Full Legal Name:
Place of Birth: Date of Birth: Sex:
Child’s Residence for the past 5 years:
Dates Address (including city and Name and present address of Relationship
(From/To) state) where child lived person child lived with to child

/present

____/____

THE FOLLOWING INFORMATION IS TRUE ABOUT CHILD # :

Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody
Jurisdiction and Enforcement Act (UCCJEA) Affidavit (03/15)
- 34 -
/present

____/____

2. Participation in custody or time-sharing proceeding(s):
[Choose only one]
____ I HAVE NOT participated as a party, witness, or in any capacity in any other litigation or custody
proceeding in this or any other state, concerning custody of or time-sharing with a child subject to this
proceeding.

____ I HAVE participated as a party, witness, or in any capacity in any other litigation or custody
proceeding in this or another state, concerning custody of or time-sharing with a child subject to this
proceeding. Explain:
a. Name of each child:
b. Type of proceeding:
c. Court and state:
d. Date of court order or judgment (if any):

3. Information about custody or time-sharing proceeding(s):
[Choose only one]
____ I HAVE NO INFORMATION of any custody or time-sharing proceeding pending in a court of this
or any other state concerning a child subject to this proceeding.

____ I HAVE THE FOLLOWING INFORMATION concerning a custody or time-sharing proceeding
pending in a court of this or another state concerning a child subject to this proceeding, other than set
out in item 2. Explain:
e. Name of each child:
f. Type of proceeding:
g. Court and state:
h. Date of court order or judgment (if any):

4. Persons not a party to this proceeding:
[Choose only one]

Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody
Jurisdiction and Enforcement Act (UCCJEA) Affidavit (03/15)
- 35 -
____ I DO NOT KNOW OF ANY PERSON not a party to this proceeding who has physical custody or
claims to have custody, visitation or time-sharing with respect to any child subject to this proceeding.

____ I KNOW THAT THE FOLLOWING NAMED PERSON(S) not a party to this proceeding has (have)
physical custody or claim(s) to have custody, visitation, or time-sharing with respect to any child
subject to this proceeding:
a. Name and address of person:

_____ has physical custody _____ claims custody rights _____ claims visitation or time-sharing
Name of each child:

b. Name and address of person:

_____ has physical custody _____ claims custody rights _____ claims visitation or time-sharing
Name of each child:

c. Name and address of person:

_____ has physical custody _____ claims custody rights _____claims visitation or time-sharing
Name of each child:

5. Knowledge of prior child support proceedings:
[Choose only one]
_____The child(ren) described in this affidavit are NOT subject to existing child support order(s) in this
or any state or territory.

Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody
Jurisdiction and Enforcement Act (UCCJEA) Affidavit (03/15)
- 36 -
_____The child(ren) described in this affidavit are subject to the following existing child support
order(s):
a. Name of each child: ______________________________________________________
b. Type of proceeding: ______________________________________________________
c. Court and address: _______________________________________________________
d. Date of court order/judgment (if any): ___________________________________________
e. Amount of child support paid and by whom:

6. I acknowledge that I have a continuing duty to advise this Court of any custody, visitation or time-
sharing, child support, or guardianship proceeding (including dissolution of marriage, separate
maintenance, child neglect, or dependency) concerning the child(ren) in this state or any other
state about which information is obtained during this proceeding.

I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand
delivered to the person(s) listed below on {date} .

Other party or his/her attorney:
Name:
Address:
City, State, Zip: ______
Fax Number:
Designated E-mail Address(es):____________________
_____________________________________________

I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
affidavit and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.

Dated: ______________________

Signature of Party
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es):____________________
_____________________________________________

STATE OF FLORIDA
COUNTY OF ________________________

Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody
Jurisdiction and Enforcement Act (UCCJEA) Affidavit (03/15)
- 37 -
Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

[Print, type, or stamp commissioned name of notary or clerk.]
__ Personally known
__ Produced identification
Type of identification produced _______________________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Husband ( ) Wife
This form was completed with the assistance of:
{name of individual} _________________________________________________________________,
{name of business} __________________________________________________________________,
{address} __________________________________________________________________________,
{city} ______________,{state} _____,{zip code}___________,{telephone number} ______________ .

Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody
Jurisdiction and Enforcement Act (UCCJEA) Affidavit (03/15)
- 38 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.902(f)(1)
MARITAL SETTLEMENT AGREEMENT FOR DISSOLUTION OF MARRIAGE
WITH DEPENDENT OR MINOR CHILD(REN)(03/15)

When should this form be used?

This form should be used when a Petition for Dissolution of Marriage with Dependent or Minor
Child(ren), Florida Supreme Court Approved Family Law Form 12.901(b)(1), has been filed and the
parties have reached an agreement on some or all of the issues at hand.

This form should be typed or printed in black ink. Both parties must sign the agreement and have their
signatures witnessed by a notary public or deputy clerk. After completing this form, you should file the
original with the clerk of the circuit court in the county where the petition was filed and keep a copy for
your records. You should then refer to the instructions for your petition, answer, or answer and
counterpetition concerning the procedures for setting a hearing or trial (final hearing).

IMPORTANT INFORMATION REGARDING E-FILING

Where can I look for more information?

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions for Florida Supreme Court Approved Family Law Form 12.902(f)(1), Marital
Settlement Agreement for Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
- 39 -
Administration.

Special notes...

With this form you must also file a Child Support Guidelines Worksheet, Florida Family Law Rules of
Procedure Form 12.902(e), if not already filed.

This form does not act to transfer title to the property. Such transfer must be done by deed or
supplemental final judgment.

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Case No.: ___________________
Division: ____________________

In re: the Marriage of:

,
Husband,

and

,
Wife.

MARITAL SETTLEMENT AGREEMENT FOR DISSOLUTION OF MARRIAGE
WITH DEPENDENT OR MINOR CHILD(REN)

We, {Husband’s full legal name}_______________________________________________, and
{Wife’s full legal name,_______________________________________________________ being sworn,
certify that the following statements are true:

1. We were married to each other on {date} .

2. Because of irreconcilable differences in our marriage (no chance of staying together), we have
made this agreement to settle once and for all what we owe to each other and what we can
expect to receive from each other. Each of us states that nothing has been held back, that we
have honestly included everything we could think of in listing our assets (everything we own and
that is owed to us) and our debts (everything we owe), and that we believe the other has been
open and honest in writing this agreement.

3. We have both filed a Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form
12.902(b) or (c). Because we have voluntarily made full and fair disclosure to each other of all
our assets and debts, we waive any further disclosure under rule 12.285, Florida Family Law
Rules of Procedure.

4. Each of us agrees to execute and exchange any papers that might be needed to complete this
agreement, including deeds, title certificates, etc.

SECTION I. MARITAL ASSETS AND LIABILITIES
A. Division of Assets. We divide our assets (everything we own and that is owed to us) as follows: Any
personal item(s) not listed below is (are) the property of the party currently in possession of the

Florida Supreme Court Approved Family Law Form 12.902(f)(1), Marital Settlement Agreement
for Dissolution of Marriage with Dependent or Minor Child(ren)(03/15)
- 41 -
item(s).

1. Wife shall receive as her own and Husband shall have no further rights or responsibilities
regarding these assets:
ASSETS: DESCRIPTION OF ITEM(S) WIFE SHALL RECEIVE Current Fair
Please describe each item as clearly as possible. Market Value
You do not need to list account numbers. Where applicable, include whether the
name on any title/deed/account described below is wife’s, husband’s, or both.
Cash (on hand) $
Cash (in banks/credit unions)

Stocks/Bonds

Notes (money owed to you in writing)

Money owed to you (not evidenced by a note)

Real estate: (Home)
(Other)

Business interests

Automobiles

Boats
Other vehicles

Retirement plans (Profit Sharing, Pension, IRA, 401(k)s, etc.)

Furniture & furnishings in home

Furniture & furnishings elsewhere

Collectibles

Florida Supreme Court Approved Family Law Form 12.902(f)(1), Marital Settlement Agreement
for Dissolution of Marriage with Dependent or Minor Child(ren)(03/15)
- 42 -
ASSETS: DESCRIPTION OF ITEM(S) WIFE SHALL RECEIVE Current Fair
Please describe each item as clearly as possible. Market Value
You do not need to list account numbers. Where applicable, include whether the
name on any title/deed/account described below is wife’s, husband’s, or both.

Jewelry

Life insurance (cash surrender value)

Sporting and entertainment (T.V., stereo, etc.) equipment

Other assets

Total Assets to Wife $

2. Husband shall receive as his own and Wife shall have no further rights or responsibilities regarding
these assets:
ASSETS: DESCRIPTION OF ITEM(S) HUSBAND SHALL RECEIVE Current Fair
Please describe each item as clearly as possible. Market Value
You do not need to list account numbers. Where applicable, include whether the
name on any title/deed/account described below is wife’s, husband’s or both.
Cash (on hand) $
Cash (in banks/credit unions)

Stocks/Bonds

Notes (money owed to you in writing)

Money owed to you (not evidenced by a note)

Florida Supreme Court Approved Family Law Form 12.902(f)(1), Marital Settlement Agreement
for Dissolution of Marriage with Dependent or Minor Child(ren)(03/15)
- 43 -
ASSETS: DESCRIPTION OF ITEM(S) HUSBAND SHALL RECEIVE Current Fair
Please describe each item as clearly as possible. Market Value
You do not need to list account numbers. Where applicable, include whether the
name on any title/deed/account described below is wife’s, husband’s or both.

Real estate: (Home)
(Other)

Business interests

Automobiles

Boats
Other vehicles

Retirement plans (Profit Sharing, Pension, IRA, 401(k)s, etc.)

Furniture & furnishings in home

Furniture & furnishings elsewhere

Collectibles

Jewelry

Life insurance (cash surrender value)

Sporting and entertainment (T.V., stereo, etc.) equipment

Other assets

Florida Supreme Court Approved Family Law Form 12.902(f)(1), Marital Settlement Agreement
for Dissolution of Marriage with Dependent or Minor Child(ren)(03/15)
- 44 -
ASSETS: DESCRIPTION OF ITEM(S) HUSBAND SHALL RECEIVE Current Fair
Please describe each item as clearly as possible. Market Value
You do not need to list account numbers. Where applicable, include whether the
name on any title/deed/account described below is wife’s, husband’s or both.

Total Assets to Husband $

Florida Supreme Court Approved Family Law Form 12.902(f)(1), Marital Settlement Agreement
for Dissolution of Marriage with Dependent or Minor Child(ren)(03/15)
- 45 -
B. Division of Liabilities/Debts. We divide our liabilities (everything we owe) as follows:
1. Wife shall pay as her own the following and will not at any time ask Husband to pay these
debts/bills:
LIABILITIES: DESCRIPTION OF DEBT(S) TO BE PAID BY WIFE
Please describe each item as clearly as possible. You do not need to list Current
account numbers. Where applicable, include whether the name on any Monthly Amount
mortgage, note, or account described below is wife’s, husband’s, or both Payment Owed
Mortgages on real estate: (Home) $ $
(Other)

Charge/credit card accounts

Auto loan
Auto loan
Bank/credit union loans

Money you owe (not evidenced by a note)

Judgments

Other

Total Debts to Be Paid by Wife $ $

Florida Supreme Court Approved Family Law Form 12.902(f)(1), Marital Settlement Agreement
for Dissolution of Marriage with Dependent or Minor Child(ren)(03/15)
- 46 -
2. Husband shall pay as his own the following and will not at any time ask Wife to pay these
debts/bills:
LIABILITIES: DESCRIPTION OF DEBT(S) TO BE PAID BY HUSBAND
Please describe each item as clearly as possible. You do not need to list Current
account numbers. Where applicable, include whether the name on any Monthly Amount
mortgage, note or account described below is wife’s, husband’s, or both. Payment Owed
Mortgages on real estate: (Home) $ $
(Other)

Charge/credit card accounts

Auto loan
Auto loan
Bank/credit union loans

Money you owe (not evidenced by a note)

Judgments

Other

Total Debts to Be Paid by Husband $ $

C. Contingent Assets and Liabilities (listed in Section III of our Family Law Financial Affidavits) will be
divided as follows:

Florida Supreme Court Approved Family Law Form 12.902(f)(1), Marital Settlement Agreement
for Dissolution of Marriage with Dependent or Minor Child(ren)(03/15)
- 47 -
.

D. Beneficiary Designation (Complete only if beneficiary designations continue after entry of Final
Judgment of Dissolution of Marriage.)

_____The Husband and Wife agree that the designation providing for the payment or transfer at death
of an interest in the assets set forth below to or for the benefit of the deceased party’s former spouse
SHALL NOT BE VOID as of the date of entry of the Final Judgment of Dissolution of Marriage.
The Final Judgment of Dissolution of Marriage shall provide that the designations set forth below remain
in full force and effect:
_____1. The _____Husband _____Wife shall acquire or maintain the following assets for the benefit of
the other spouse or child(ren) to be paid upon his/her death outright or in trust. This provision only
applies if other assets fulfilling such requirement for the benefit of the other spouse or child(ren) do not
exist upon his/her death and unless precluded by statute. {Describe the assets with specificity}:
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________.
_____2. The _____Husband _____Wife shall not unilaterally terminate or modify the ownership of the
following assets, or their disposition upon his/her death. {Describe the assets with specificity}:_________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ .

SECTION II. SPOUSAL SUPPORT (ALIMONY) (If you have not agreed on this matter, write n/a on the
lines provided.)

1. ____Each of us forever gives up any right to spousal support (alimony) that we may have.

OR
2. _____ HUSBAND _____ WIFE (hereinafter “Obligor”) agrees to pay spousal support (alimony) in
the amount of $ ______every _____ week _____ other week _____month, beginning
{date} _________________and continuing until {date or event} __________________
_____________________________________________________________________________.
{Explain type of alimony (such as, permanent, bridge-the-gap, durational, rehabilitative, and/or
lump sum) and any other specifics}:__________________________________________________

Florida Supreme Court Approved Family Law Form 12.902(f)(1), Marital Settlement Agreement
for Dissolution of Marriage with Dependent or Minor Child(ren)(03/15)
- 48 -
4. Life insurance in the amount of $____________ to secure the above support, will be provided
by the Obligor.

SECTION III. PARENTING PLAN ESTABLISHING PARENTAL RESPONSIBILITY AND TIME-SHARING

1. The parties’ minor child(ren) are:
Name Birth date

2. The parties shall have time-sharing and parental responsibility in accordance with the Parenting
Plan attached as Exhibit _____.

SECTION IV. CHILD SUPPORT

1. _____ Wife ____ Husband (hereinafter “Obligor”) will pay child support, under Florida’s child
support guidelines, section 61.30, Florida Statutes, to the other parent. The Child Support
Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e), is completed and
attached.

Child support established at the rate of $_________ per month for the ______children {total number of
parties’ minor or dependent children} shall be paid commencing _________________ {month, day, year}
and terminating ___________________ {month, day, year}. Child support shall be paid in the amount of
$ __________ per ___________ {week, month, other} which is consistent with the Obligor’s current
payroll cycle.

Upon the termination of the obligation of child support for one of the parties’ children, child support in
the amount of $____________ for the remaining ____ children {total number of remaining children}
shall be paid commencing____________________ {month, day, year} and terminating
________________________________________ {month, day, year}. This child support shall be paid in
the amount of $ ________ per ___________ {week, month, other} consistent with Obligor’s current
payroll cycle.

{Insert schedule for the child support obligation, including the amount, and commencement and
termination dates, for the remaining minor or dependent children, which shall be payable as the
obligation for each child ceases. Please indicate whether the schedule _____appears below or
_____is attached as part of this form}
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Florida Supreme Court Approved Family Law Form 12.902(f)(1), Marital Settlement Agreement
for Dissolution of Marriage with Dependent or Minor Child(ren)(03/15)
- 49 -
_____________________________________________________________________________

The Obligor shall pay child support until all the minor or dependent child(ren): reach the age of 18;
become emancipated, marry, join the armed services, die, or become self-supporting; or until further
order of the court or agreement of the parties. The child support obligation shall continue beyond the
age of 18 and until high school graduation for any child who is: dependent in fact; between the ages of
18 and 19; and is still in high school, performing in good faith with a reasonable expectation of
graduation before the age of 19.

If the child support amount above deviates from the guidelines by 5% or more, explain the reason(s)
here: ______________________________________________________________________________

2. Child Support Arrearage. There currently is a child support arrearage of $ _____
for retroactive child support and/or $ ____ for previously ordered unpaid child
support. The total of $ _ in child support arrearage shall be repaid at the rate of
$ ______ every _____ week _____ other week _____month, beginning {date}
________________, until paid in full including statutory interest.

3. Health Insurance. _____ Wife _____ Husband will maintain health insurance for the
parties’ minor child(ren). The party providing coverage will provide insurance cards to the other
party showing coverage. OR ( ) Health insurance is either not reasonable in cost or accessible
to the child(ren) at this time. Any uninsured/ unreimbursed medical costs for the minor
child(ren) shall be assessed as follows:
a. _____Shared equally by husband and wife.
b. _____Prorated according to the child support guideline percentages.
c. _____Other {explain}: __________________________________________________
As to these uninsured/unreimbursed medical expenses, the party who incurs the expense shall submit a
request for reimbursement to the other party within 30 days, and the other party, within 30 days of
receipt, shall submit the applicable reimbursement for that expense, according to the schedule of
reimbursement set out in this paragraph.

4. Dental Insurance.
_____ Wife ____ Husband will maintain dental insurance for the parties’ minor child(ren). The party
providing coverage will provide insurance cards to the other party showing coverage

OR
_____ Dental insurance is either not reasonable in cost or accessible to the child(ren) at this time.
Any uninsured/ unreimbursed dental costs for the minor child(ren) shall be assessed as follows:
a. _____Shared equally by husband and wife.
b. _____Prorated according to the child support guideline percentages.
c. _____Other {explain}: __________________________________________________
As to these uninsured/unreimbursed dental expenses, the party who incurs the expense shall submit a
request for reimbursement to the other party within 30 days, and the other party, within 30 days of
receipt, shall submit the applicable reimbursement for that expense, according to the schedule of

Florida Supreme Court Approved Family Law Form 12.902(f)(1), Marital Settlement Agreement
for Dissolution of Marriage with Dependent or Minor Child(ren)(03/15)
- 50 -
reimbursement set out in this paragraph.

5. Life Insurance. _____ Wife _____ Husband will maintain life insurance for the benefit of the
parties’ minor child(ren) in the amount of $ _________ until the youngest child turns 18,
becomes emancipated, marries, joins the armed services, or dies.

6. IRS Income Tax Exemption(s). The assignment of any tax exemptions for the child(ren) shall be
as follows: {explain}
____________________________________________________________________
____________________________________________________________________________________.
The other parent will convey any applicable IRS form regarding the income tax exemption.

7. ______Other provisions relating to child support (e.g., uninsured medical/dental expenses, health or
dental insurance, life insurance to secure child support, orthodontic payments, college fund, etc.):

_____________________________________________________________________________________
____________________________________________________________________________________.

SECTION V. OTHER

_____________________________________________________________________________________
____________________________________________________________________________________.

SECTION VI. We have not agreed on the following issues:

Florida Supreme Court Approved Family Law Form 12.902(f)(1), Marital Settlement Agreement
for Dissolution of Marriage with Dependent or Minor Child(ren)(03/15)
- 51 -
I certify that I have been open and honest in entering into this settlement agreement. I am satisfied
with this agreement and intend to be bound by it.

Dated:

____________________________________________________________
Signature of Husband
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es): __________________
__________________________________________

STATE OF FLORIDA
COUNTY OF ____________________

Sworn to or affirmed and signed before me on ____________ by _______________________________.

_____________________________________________
NOTARY PUBLIC or DEPUTY CLERK

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Husband ( ) Wife
This form was completed with the assistance of:
{name of individual} _________________________________________________________________,
{name of business} __________________________________________________________________,
{address} __________________________________________________________________________,
{city} ______________,{state} _____,{zip code}___________,{telephone number} ________________.

Florida Supreme Court Approved Family Law Form 12.902(f)(1), Marital Settlement Agreement
for Dissolution of Marriage with Dependent or Minor Child(ren)(03/15)
- 52 -
I certify that I have been open and honest in entering into this settlement agreement. I am satisfied
with this agreement and intend to be bound by it.

Dated:
_________________________________________
Signature of Wife
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es): __________________
__________________________________________
STATE OF FLORIDA
COUNTY OF ____________________

Sworn to or affirmed and signed before me on ____________ by _______________________________.

_____________________________________________
NOTARY PUBLIC or DEPUTY CLERK

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Husband ( ) Wife
This form was completed with the assistance of:
{name of individual} _________________________________________________________________,
{name of business} __________________________________________________________________,
{address} __________________________________________________________________________,
{city} ______________,{state} _____,{zip code}___________,{telephone number} ________________.

Florida Supreme Court Approved Family Law Form 12.902(f)(1), Marital Settlement Agreement
for Dissolution of Marriage with Dependent or Minor Child(ren)(03/15)
- 53 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.902(f)(2)
MARITAL SETTLEMENT AGREEMENT FOR DISSOLUTION OF MARRIAGE
WITH PROPERTY BUT NO DEPENDENT OR MINOR CHILD(REN)
(03/15)

When should this form be used?

This form should be used when a Petition for Dissolution of Marriage with Property but no Dependent
or Minor Child(ren), Florida Supreme Court Approved Family Law Form 12.901(b)(2), has been filed and
the parties have reached an agreement on some or all of the issues at hand.

IMPORTANT INFORMATION REGARDING E-FILING

Where can I look for more information?

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions for Florida Supreme Court Approved Family Law Form 12.902(f)(2), Marital
Settlement Agreement for Dissolution of Marriage with Property but No Dependent or Minor
Child(ren) (03/15)
- 54 -
After the initial service of process of the petition or supplemental petition by the Sheriff or certified
process server, the Florida Rules of Judicial Administration now require that all documents required or
permitted to be served on the other party must be served by electronic mail (e-mail) except in certain
circumstances. You must strictly comply with the format requirements set forth in the Rules of Judicial
Administration.

Special notes...

This form does not act to transfer title to the property. Such transfer must be done by deed or
supplemental final judgment.

Case No.: _______________
Division: _______________
In re: the Marriage of:

_________________,
Husband,

and

______________,
Wife.

MARITAL SETTLEMENT AGREEMENT FOR DISSOLUTION OF MARRIAGE
WITH PROPERTY BUT NO DEPENDENT OR MINOR CHILD(REN)

We, {Husband’s full legal name}_____________________________________and {Wife’s full legal name}
__________________________________________, being sworn, certify that the following statements
are true:

1. We were married to each other on {date} .

Florida Supreme Court Approved Family Law Form 12.902(f)(2), Marital Settlement Agreement
for Dissolution of Marriage with Property but No Dependent or Minor Child(ren) (03/15)
- 56 -
4. Each of us agrees to execute and exchange any papers that might be needed to complete this
agreement, including deeds, title certificates, etc.

SECTION I. MARITAL ASSETS AND LIABILITIES
A. Division of Assets. We divide our assets (everything we own and that is owed to us) as follows: Any
personal item(s) not listed below is the property of the party currently in possession of the item(s).

1. Wife shall receive as her own and Husband shall have no further rights or responsibilities
regarding these assets:

ASSETS: DESCRIPTION OF ITEM(S) WIFE SHALL RECEIVE Current Fair
Market Value
Please describe each item as clearly as possible. You do not need to list account
numbers. Where applicable, include whether the name on any title/deed/account
described below is wife’s, husband’s, or both.
Cash (on hand) $
Cash (in banks/credit unions)

Stocks/Bonds

Notes (money owed to you in writing)

Money owed to you (not evidenced by a note)

Real estate: (Home)
(Other)

Business interests

Automobiles

Boats
Other vehicles

Florida Supreme Court Approved Family Law Form 12.902(f)(2), Marital Settlement Agreement
for Dissolution of Marriage with Property but No Dependent or Minor Child(ren) (03/15)
- 57 -
Retirement plans (Profit Sharing, Pension, IRA, 401(k)s, etc.)

Furniture & furnishings in home

Furniture & furnishings elsewhere

Collectibles

Jewelry

Life insurance (cash surrender value)

Sporting and entertainment (T.V., stereo, etc.) equipment

Other assets

Total Assets to Wife $

2. Husband shall receive as his own and Wife shall have no further rights or responsibilities
regarding these assets:

ASSETS: DESCRIPTION OF ITEM(S) HUSBAND SHALL RECEIVE Current Fair
Please describe each item as clearly as possible. You do not need to list account Market Value
numbers. Where applicable, include whether the name on any title/deed/account
described below is wife’s, husband’s or both.
Cash (on hand) $
Cash (in banks/credit unions)

Florida Supreme Court Approved Family Law Form 12.902(f)(2), Marital Settlement Agreement
for Dissolution of Marriage with Property but No Dependent or Minor Child(ren) (03/15)
- 58 -
Stocks/Bonds

Notes (money owed to you in writing)

Money owed to you (not evidenced by a note)

Real estate: (Home)
(Other)

Business interests

Automobiles

Boats
Other vehicles

Retirement plans (Profit Sharing, Pension, IRA, 401(k)s, etc.)

Furniture & furnishings in home

Furniture & furnishings elsewhere

Collectibles

Jewelry

Life insurance (cash surrender value)

Sporting and entertainment (T.V., stereo, etc.) equipment

Florida Supreme Court Approved Family Law Form 12.902(f)(2), Marital Settlement Agreement
for Dissolution of Marriage with Property but No Dependent or Minor Child(ren) (03/15)
- 59 -
Other assets

Total Assets to Husband $

B. Division of Liabilities/Debts. We divide our liabilities (everything we owe) as follows:
1. Wife shall pay as her own the following and will not at any time ask Husband to pay these
debts/bills:

LIABILITIES: DESCRIPTION OF DEBT(S) TO BE PAID BY WIFE
Please describe each item as clearly as possible. You do not need to list Current
account numbers. Where applicable, include whether the name on any Monthly Amount
mortgage, note, or account described below is wife’s, husband’s, or both. Payment Owed
Mortgages on real estate: (Home) $ $
(Other)

Charge/credit card accounts

Auto loan
Auto loan
Bank/credit union loans

Money you owe (not evidenced by a note)

Judgments

Florida Supreme Court Approved Family Law Form 12.902(f)(2), Marital Settlement Agreement
for Dissolution of Marriage with Property but No Dependent or Minor Child(ren) (03/15)
- 60 -
Other

Total Debts to Be Paid by Wife $ $

2. Husband shall pay as his own the following and will not at any time ask Wife to pay these
debts/bills:
LIABILITIES: DESCRIPTION OF DEBT(S) TO BE PAID BY HUSBAND
Please describe each item as clearly as possible. You do not need to list Current
account numbers. Where applicable, include whether the name on any Monthly Amount
mortgage, note or account described below is wife’s, husband’s, or both. Payment Owed
Mortgages on real estate: (Home) $ $
(Other)

Charge/credit card accounts

Auto loan
Auto loan
Bank/credit union loans

Money you owe (not evidenced by a note)

Judgments

Other

Total Debts to Be Paid by Husband $ $

Florida Supreme Court Approved Family Law Form 12.902(f)(2), Marital Settlement Agreement
for Dissolution of Marriage with Property but No Dependent or Minor Child(ren) (03/15)
- 61 -
C. Contingent Assets and Liabilities (listed in Section III of our Family Law Financial Affidavits) will be
divided as follows:

D. Beneficiary Designation (Complete only if beneficiary designations continue after entry of Final
Judgment of Dissolution of Marriage.)

The Final Judgment of Dissolution of Marriage shall provide that the designations set forth below remain
in full force and effect:

_____1. The _____Husband _____Wife shall acquire or maintain the following assets for the benefit of
the other spouse or child(ren) to be paid upon his/her death outright or in trust. This provision only
applies if other assets fulfilling such requirement for the benefit of the other spouse or child(ren) do not
exist upon his/her death and unless precluded by statute. {Describe the assets with specificity}:
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________.

_____2. The _____Husband _____Wife shall not unilaterally terminate or modify the ownership of the
following assets, or their disposition upon his/her death. {Describe the assets with specificity}:_________
___________________________________________________________________________________
___________________________________________________________________________________
____________________________________________________________________________________.

SECTION II. SPOUSAL SUPPORT (ALIMONY) (If you have not agreed on this matter, write n/a on the
lines provided.)

1. ____ Each of us forever gives up any right to spousal support (alimony) that we may have.

2. _____ HUSBAND _____ WIFE (hereinafter “Obligor”) agrees to pay spousal support (alimony) in
the amount of $ _______every _____week _____other week _____ month, beginning

Florida Supreme Court Approved Family Law Form 12.902(f)(2), Marital Settlement Agreement
for Dissolution of Marriage with Property but No Dependent or Minor Child(ren) (03/15)
- 62 -
{date} ___________________________ and continuing until {date or event}____________
____________________________________________________________________________.

Explain type of alimony (permanent, bridge-the-gap, durational, rehabilitative, and/or lump sum) and
any other specifics:

3. _____Other provisions relating to alimony, including any tax treatment and consequences:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

4. _____ Husband _____ Wife will provide life insurance in the amount of $______________to
secure the above support.

SECTION III. OTHER

_____________________________________________________________________________________
_______________________________________________________________________ .

SECTION IV. We have not agreed on the following issues:

______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________________
_______________________________________________________________________ .

I certify that I have been open and honest in entering into this settlement agreement. I am satisfied
with this agreement and intend to be bound by it.

Dated:
Signature of Husband

Florida Supreme Court Approved Family Law Form 12.902(f)(2), Marital Settlement Agreement
for Dissolution of Marriage with Property but No Dependent or Minor Child(ren) (03/15)
- 63 -
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es): __________________
__________________________________________

STATE OF FLORIDA
COUNTY OF ____________________

Sworn to or affirmed and signed before me on ____________ by _______________________________.

_____________________________________________
NOTARY PUBLIC or DEPUTY CLERK

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Husband ( ) Wife
This form was completed with the assistance of:
{name of individual} _________________________________________________________________,
{name of business} __________________________________________________________________,
{address} __________________________________________________________________________,
{city} ______________,{state} _____,{zip code}___________,{telephone number} ________________.

Florida Supreme Court Approved Family Law Form 12.902(f)(2), Marital Settlement Agreement
for Dissolution of Marriage with Property but No Dependent or Minor Child(ren) (03/15)
- 64 -
I certify that I have been open and honest in entering into this settlement agreement. I am satisfied
with this agreement and intend to be bound by it.

Dated:
Signature of Wife
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es): __________________
__________________________________________
STATE OF FLORIDA
COUNTY OF ____________________

Sworn to or affirmed and signed before me on ____________ by _______________________________.

_____________________________________________
NOTARY PUBLIC or DEPUTY CLERK

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Husband ( ) Wife
This form was completed with the assistance of:
{name of individual} _________________________________________________________________,
{name of business} __________________________________________________________________,
{address} __________________________________________________________________________,
{city} ______________,{state} _____,{zip code}___________,{telephone number} ________________.

Florida Supreme Court Approved Family Law Form 12.902(f)(2), Marital Settlement Agreement
for Dissolution of Marriage with Property but No Dependent or Minor Child(ren) (03/15)
- 65 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.902(i),
AFFIDAVIT OF CORROBORATING WITNESS (03/15)

When should this form be used?

This form may be used to prove residency in a dissolution of marriage proceeding. To get a divorce in
Florida, either the husband or the wife must have lived in Florida for at least 6 months before filing the
petition. Residency may be proved by a valid Florida’s driver’s license, Florida identification card, or
voter’s registration card (issue date of document must be at least 6 months before the date the case is
actually filed with the clerk of the circuit court), or the testimony or affidavit of someone other than you
or your spouse. This form is used to prove residency by affidavit. The person signing this form must
know that you have lived in the State of Florida for at least 6 months before the date you filed your
petition for dissolution of marriage.

This form should be typed or printed in black ink, and signed in the presence of a notary public or
deputy clerk. After completing this form, you should file the original with the clerk of the circuit court
in the county where the petition was filed and keep a copy for you records.

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?

A copy of this form must be mailed, e-mailed, or hand delivered to the other party in your case, if it is
not served on him or her with your initial papers.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions for Florida Supreme Court Approved Family Law Form 12.902(i), Affidavit of
Corroborating Witness (03/15)
- 66 -
SELF-REPRESENTED LITIGANTS MAY SERVE DOCUMENTS BY E-MAIL; HOWEVER, THEY ARE NOT
REQUIRED TO DO SO. If a self-represented litigant elects to serve and receive documents by e-mail, the
procedures must always be followed once the initial election is made.

Where can I look for more information?

Before proceeding, you should read General Information for Self-Represented Litigants found at the
beginning of these forms. The words that are in “bold underline” in these instructions are defined
there. For further information, see chapter 61, Florida Statutes.

Special notes…

Instructions for Florida Supreme Court Approved Family Law Form 12.902(i), Affidavit of
Corroborating Witness (03/15)
- 67 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:

,
Husband,

and

,
Wife.

AFFIDAVIT OF CORROBORATING WITNESS
I, {full legal name} , being sworn, certify that the
following statements are true: I have known {name}
________ since {approximate date} ; to the best of my understanding the
petition in this action was filed on {date} _____; and I know of my own personal
knowledge that this person has resided in the State of Florida for at least 6 months immediately before
{date} _________.

I understand that I am swearing or affirming under oath to the truthfulness of the claims
made in this affidavit and that the punishment for knowingly making a false statement includes fines
and/or imprisonment.

Dated:
Signature of Corroborating Witness
Printed Name:
Address:
City, State, Zip:
Telephone Number:
STATE OF FLORIDA
COUNTY OF

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

[Print, type, or stamp commissioned name of notary or
clerk.]

____ Personally known
____ Produced identification
Florida Supreme Court Approved Family Law Form 12.902(i), Affidavit of Corroborating Witness
(03/15)
- 68 -
Type of identification produced

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Husband ( ) Wife
This form was completed with the assistance of:
{name of individual} _________________________________________________________________,
{name of business} __________________________________________________________________,
{address} __________________________________________________________________________,
{city} ______________,{state} _____,{zip code}___________,{telephone number} ________________.

Florida Supreme Court Approved Family Law Form 12.902(i), Affidavit of Corroborating Witness
(03/15)
- 69 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.902(j),
NOTICE OF SOCIAL SECURITY NUMBER (03/15)

When should this form be used?

This form must be completed and filed by each party in all paternity, child support, and dissolution of
marriage cases, regardless of whether the case involves a minor child(ren) and/or property.

This form should be typed or printed in black ink. After completing this form, you should file the original
with the clerk of the circuit court in the county where your case was filed and keep a copy for your
records.

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?

A copy of this form must be mailed, e-mailed, or hand delivered to the other party in your case, if it is
not served on him or her with your initial papers.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions for Florida Supreme Court Approved Family Law Form 12.902(j), Notice of Social
Security Number (03/15)
- 70 -
To serve and receive documents by e-mail, you must designate your e-mail addresses by using the
Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family Law Form
12.915, and you must provide your e-mail address on each form on which your signature appears.
Please CAREFULLY read the rules and instructions for: Certificate of Service (General), Florida Supreme
Court Approved Family Law Form 12.914; Designation of Current Mailing and E-mail Address, Florida
Supreme Court Approved Family Law Form 12.915; and Florida Rule of Judicial Administration 2.516.

Where can I look for more information?

Special notes...

If this is a domestic violence case and you want to keep your address confidential for safety reasons,
do not enter the address, telephone, fax, or e-mail information at the bottom of this form. Instead, file
a Request for Confidential Filing of Address, Florida Supreme Court Approved Family Law Form
12.980(i).

Instructions for Florida Supreme Court Approved Family Law Form 12.902(j), Notice of Social
Security Number (03/15)
- 71 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
,
Petitioner,

and

,
Respondent.

NOTICE OF SOCIAL SECURITY NUMBER
I, {full legal name} ___________________________________________________________, certify that
my social security number is ___________________________, as required by the applicable section of
the Florida Statutes. My date of birth is ______________________________.

[Choose one only]
__ 1. This notice is being filed in a dissolution of marriage case in which the parties have no minor
children in common.

__ 2. This notice is being filed in a paternity or child support case, or in a dissolution of marriage
in which the parties have minor children in common. The minor child(ren)'s name(s), date(s) of birth,
and social security number(s) is/are:

Name Birth date Social Security Number
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
{Attach additional pages if necessary.}

Florida Supreme Court Approved Family Law Form 12.902(j), Notice of Social Security Number
(03/15)
- 72 -
Disclosure of social security numbers shall be limited to the purpose of administration of the Title IV-D
program for child support enforcement.

Florida Supreme Court Approved Family Law Form 12.902(j), Notice of Social Security Number
(03/15)
- 73 -
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
notice and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.

Dated: ___________________
_____________________________________________
Signature
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es):____________________
_______________________________________

STATE OF FLORIDA
COUNTY OF ________

Sworn to or affirmed and signed before me on by .

__________________
NOTARY PUBLIC or DEPUTY CLERK

___________________
[Print, type, or stamp commissioned name of notary or
clerk]

Personally known
Produced identification
Type of identification produced __________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent
This form was completed with the assistance of:
{name of individual} _________________________________________________________________,
{name of business} __________________________________________________________________,
{address} __________________________________________________________________________,
{city} ______________,{state} _____,{zip code}___________,{telephone number} ________________.

Florida Supreme Court Approved Family Law Form 12.902(j), Notice of Social Security Number
(03/15)
- 74 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY
LAW FORM 12.903(a)
ANSWER, WAIVER, AND REQUEST FOR COPY OF FINAL JUDGMENT OF
DISSOLUTION OF MARRIAGE (03/15)

When should this form be used?

This form should be used when you have been served with a petition for dissolution of marriage
and you do not wish to contest it or appear at a hearing. If you file this form, you are admitting all
of the allegations in the petition, saying that you do not need to be notified of or appear at the final
hearing, and that you would like a copy of the final judgment mailed to you.
This form should be typed or printed in black ink, and your signature should be witnessed by a
notary public or deputy clerk. After completing this form, you should sign the form before a notary
public. You should file the original with the clerk of the circuit court in the county where the
petition was filed and keep a copy for your records. The person filing the petition in a dissolution of
marriage proceeding is also referred to as the petitioner and his or her spouse as the respondent.

IMPORTANT INFORMATION REGARDING E-FILING

The Florida Rules of Judicial Administration now require that all petitions, pleadings, and documents
be filed electronically except in certain circumstances. Self-represented litigants may file petitions
or other pleadings or documents electronically; however, they are not required to do so. If you
choose to file your pleadings or other documents electronically, you must do so in accordance with
Florida Rule of Judicial Administration 2.525, and you must follow the procedures of the judicial
circuit in which you file. The rules and procedures should be carefully read and followed.

What should I do next?
You have 20 days to answer after being served with your spouse’s petition. A copy of this form,
along with all of the other forms required with this answer and waiver, must be mailed, e-mailed, or
hand delivered to your spouse.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions for Florida Supreme Court Approved Family Law Form 12.903(a), Answer,
Waiver, and Request for Copy of Final Judgment of Dissolution of Marriage (03/15)
- 75 -
Rules of Judicial Administration.
SELF-REPRESENTED LITIGANTS MAY SERVE DOCUMENTS BY E-MAIL; HOWEVER, THEY ARE NOT
REQUIRED TO DO SO. If a self-represented litigant elects to serve and receive documents by e-mail,
the procedures must always be followed once the initial election is made.

To serve and receive documents by e-mail, you must designate your e-mail addresses by using the
Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family Law
Form 12.915, and you must provide your e-mail address on each form on which your signature
appears. Please CAREFULLY read the rules and instructions for: Certificate of Service (General),
Florida Supreme Court Approved Family Law Form 12.914; Designation of Current Mailing and E-
mail Address, Florida Supreme Court Approved Family Law Form 12.915; and Florida Rule of Judicial
Administration 2.516.

Where can I look for more information?
Before proceeding, you should read General Information for Self-Represented Litigants found at
the beginning of these forms. The words that are in bold underline in these instructions are
defined there. For further information, see chapter 61, Florida Statutes.

Special notes...

With this form, you must also file the following:

 Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida
Supreme Court Approved Family Law Form 12.902(d), if the case involves a dependent or
minor child(ren).
 Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form
12.902(e), if the case involves a dependent or minor child(ren). (If you do not know the
other party’s income, you may file this worksheet after his or her financial affidavit has been
served on you).
 Marital Settlement Agreement for Dissolution of Marriage with Dependent or Minor
Child(ren), Florida Supreme Court Approved Family Law Form 12.902(f)(1), or Marital
Settlement Agreement for Dissolution of Marriage with No Dependent or Minor
Child(ren), Florida Supreme Court Approved Family Law Form 12.902(f)(2), if you have
reached an agreement on any or all of the issues.
 Notice of Social Security Number, Florida Supreme Court Approved Family Law Form
12.902(j).
 Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or (c).
(This must be filed within 45 days of service of the petition on you, if not filed at the time
you file this answer.)
 Certificate of Compliance with Mandatory Disclosure, Florida Family Law Rules of

Instructions for Florida Supreme Court Approved Family Law Form 12.903(a), Answer,
Waiver, and Request for Copy of Final Judgment of Dissolution of Marriage (03/15)
- 76 -
Procedure Form 12.932. (This must be filed within 45 days of service of the petition on you,
if not filed at the time you file this answer, unless you and the other party have agreed not
to exchange these documents.)
Parenting Plan and Time-Sharing… By filing this answer and waiver, you are agreeing to any
parenting plan and time-sharing requests in the petition. The judge may request a parenting plan
recommendation or appoint a guardian ad litem in your case. This means that a neutral person will
review your situation and report to the judge concerning parenting issues. The purpose of such
intervention is to be sure that the best interests of the child(ren) is (are) being served. For more
information, you may consult section 61.13, Florida Statutes.

A parenting course must be completed prior to entry of a final judgment. You should contact the
clerk, family law intake staff, or judicial assistant about requirements for parenting courses where
you live.

Listed below are some terms with which you should become familiar before completing your answer
to the petition. If you do not fully understand any of the terms below or their implications, you
should speak with an attorney before going any further.

 Shared Parental Responsibility
 Sole Parental Responsibility
 Supervised Time-Sharing
 No contact
 Parenting Plan
 Parenting Plan Recommendation
 Time-Sharing Schedule

Child Support... By filing this answer and waiver, you are agreeing to any child support requests in
the petition. The court may order one parent to pay child support to assist the other parent in
meeting the child(ren)’s material needs. Both parents are required to provide financial support,
but one parent may be ordered to pay a portion of his or her support for the child(ren) to the other
parent. Florida has adopted guidelines for determining the amount of child support to be paid.
These guidelines are based on the combined income of both parents and take into account the
financial contributions of both parents. You must file a Family Law Financial Affidavit, Florida
Family Law Rules of Procedure Form 12.902(b) or (c), and your spouse will be required to do the
same. From your financial affidavits, you should be able to calculate the amount of child support
that should be paid using the Child Support Guidelines Worksheet, Florida Family Law Rules of
Procedure Form 12.902(e). Because the child support guidelines take several factors into
consideration, change over time, and vary from state to state, your child support obligation may be
more or less than that of other people in seemingly similar situations.

Alimony... By filing this answer and waiver, you are agreeing to any alimony requests in the
petition. Alimony may be awarded to one spouse if the judge finds that he or she has an actual need
for it and also finds that the other spouse has the ability to pay. If you want alimony, you must

Instructions for Florida Supreme Court Approved Family Law Form 12.903(a), Answer,
Waiver, and Request for Copy of Final Judgment of Dissolution of Marriage (03/15)
- 77 -
request it in writing in a counterpetition and should not use this form. If you do not request
alimony in writing before the final hearing, it is waived (you may not request it later). You may
request permanent alimony, bridge-the-gap alimony, durational alimony, lump sum alimony, or
rehabilitative alimony.

Marital/Nonmarital Assets and Liabilities... Florida law requires an equitable distribution of
marital assets and marital liabilities. “Equitable” does not necessarily mean “equal.” Many factors,
including child support, time-sharing and alimony awards, may lead the court to make an unequal
(but still equitable) distribution of assets and liabilities. Nonmarital assets and nonmarital liabilities
are those assets and liabilities which the parties agree or the court determines belong to, or are the
responsibility of, only one of the parties. By filing this answer and waiver, you are agreeing to any
requests in the petition regarding division of assets and liabilities.

Final Judgment... You should receive a copy of the Final Judgment in the mail. If, for some reason
you do not, you should call the clerk’s office to request a copy. It is important for you to review a
copy of the Final Judgment in your case to see what happened and to know what you must do and
what you are entitled to receive.

Nonlawyer... Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer
helps you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer,
Florida Family Law Rules of Procedure Form 12.900(a), before he or she helps you. A nonlawyer
helping you fill out these forms also must put his or her name, address, and telephone number on
the bottom of the last page of every form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.903(a), Answer,
Waiver, and Request for Copy of Final Judgment of Dissolution of Marriage (03/15)
- 78 -
IN THE CIRCUIT COURT OF THE _____________________ JUDICIAL CIRCUIT,
IN AND FOR ______________________________ COUNTY, FLORIDA

Case No: ________________________
Division: ________________________
In re: the Marriage of:

_________________________________,
Husband,
and

_________________________________,
Wife.

ANSWER, WAIVER, AND REQUEST FOR COPY OF FINAL JUDGMENT OF
DISSOLUTION OF MARRIAGE

I, {full legal name} , being sworn, certify that the following
information is true:

1. I answer the Petition for Dissolution of Marriage filed in this action and admit all the allegations.
By admitting all of the allegations in the petition, I agree to all relief requested in the petition
including any requests regarding parenting and time-sharing, child support, alimony, distribution
of marital assets and liabilities, and temporary relief.

2. I hereby waive notice of hearing as well as all future notices in connection with the Petition for
Dissolution of Marriage, as filed and also waive my appearance at the final hearing.

3. I request that a copy of the Final Judgment of Dissolution of Marriage entered in this case be
provided to me at the address below.

4. If this case involves minor child(ren), a completed Uniform Child Custody Jurisdiction and
Enforcement Act (UCCJEA) Affidavit, Florida Supreme Court Approved Family Law Form
12.902(d), is filed with this answer.

5. A completed Notice of Social Security Number, Florida Supreme Court Approved Family Law
Form 12.902(j), is filed with this answer.

6. A completed Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form
12.902(b) or (c), _____ is filed with this answer or _____ will be timely filed.

Florida Supreme Court Approved Family Law Form 12.903(a), Answer, Waiver, and Request for Copy of Final
Judgment of Dissolution of Marriage (03/15)
- 79 -
I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand
delivered to the person(s) listed below on {date} __________________________.

Other party or his/her attorney:
Name: _______________________________________
Address: _____________________________________
City, State, Zip: ________________________________
Fax Number: _________________________________
Designated E-mail Address(es):___________________
___________________________________________

I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
answer and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.

Dated: ______________________ _______________________________________
Signature of ( ) HUSBAND ( ) WIFE
Printed Name: ___________________________
Address: _______________________________
City, State, Zip: __________________________
Telephone Number: ________________________
Fax Number: _____________________________
Designated E-mail Address(es): _______________
_______________________________________

STATE OF FLORIDA
COUNTY OF ____________________

Sworn to or affirmed and signed before me on __________ by ___________________________.

_______________________________________
NOTARY PUBLIC or DEPUTY CLERK

_______________________________________
[Print, type, or stamp commissioned name of notary or deputy clerk.]

____ Personally known
____ Produced identification
____ Type of identification produced ________________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Husband ( ) Wife
This form was completed with the assistance of:
{name of individual} _________________________________________________________________,
{name of business} __________________________________________________________________,
{address} __________________________________________________________________________,
{city} ______________, {state} _____,{zip code}___________,{telephone number} ________________.

Florida Supreme Court Approved Form 12.903(a), Answer, Waiver, and Request for Copy of Final Judgment of
Dissolution of Marriage (03/15)
- 80 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED
FAMILY LAW FORM 12.903(b)
ANSWER TO PETITION FOR DISSOLUTION OF MARRIAGE
(03/15)

When should this form be used?

This form should be used when you are responding to a petition for dissolution of marriage and you
wish to admit or deny all of the allegations in the petition but you do not plan to file a
counterpetition seeking relief. You can use this form to answer any petition for dissolution of
marriage, whether or not there are minor child(ren).

IMPORTANT INFORMATION REGARDING E-FILING

The Florida Rules of Judicial Administration now require that all petitions, pleadings, and documents
be filed electronically except in certain circumstances. Self-represented litigants may file petitions
or other pleadings or documents electronically; however, they are not required to do so. If you
choose to file your pleadings or other documents electronically, you must do so in accordance with
Florida Rule of Judicial Administration 2.525, and you must follow the procedures of the judicial
circuit in which you file. The rules and procedures should be carefully read and followed.

What should I do next?

A copy of this form, along with all of the other forms required with this answer, must be mailed, e-
mailed, or hand delivered to the other party in your case. You have 20 days to answer after being
served with the other party’s petition. After you file your answer, the case will generally proceed in
one of the following two ways:

UNCONTESTED... If you file an answer that agrees with everything in the other party’s petition and
you have complied with mandatory disclosure and filed all of the required papers, either party may
call the clerk, family law intake staff, or judicial assistant to set a final hearing. If you request the
final hearing, you must notify the other party of the hearing by using a Notice of Hearing (General),
Florida Supreme Court Approved Family Law Form 12.923, or other appropriate notice of hearing

Instructions for Florida Supreme Court Approved Family Law Form 12.903(b), Answer to
Petition for Dissolution of Marriage (03/15)
- 81 -
form.

CONTESTED... If you file an answer which disagrees with or denies anything in the petition, and you
are unable to settle the disputed issues, either party may file a Notice for Trial, Florida Supreme
Court Approved Family Law Form 12.924, after you have complied with mandatory disclosure and
filed all of the required papers. Some circuits may require the completion of mediation before a
final hearing may be set. You should contact the clerk, family law intake staff, or judicial assistant for
instructions on how to set your case for trial (final hearing).

Where can I look for more information?

Before proceeding, you should read “General Information for Self-Represented Litigants” found at
the beginning of these forms. The words that are in “bold underline” in these instructions are
defined there. See chapter 61, Florida Statutes, for more information.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

To serve and receive documents by e-mail, you must designate your e-mail addresses by using the
Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family Law
Form 12.915, and you must provide your e-mail address on each form on which your signature
appears. Please CAREFULLY read the rules and instructions for: Certificate of Service (General),
Florida Supreme Court Approved Family Law Form 12.914; Designation of Current Mailing and E-
mail Address, Florida Supreme Court Approved Family Law Form 12.915; and Florida Rule of Judicial
Administration 2.516.

Special notes...

With this form, you must also file the following:

Instructions for Florida Supreme Court Approved Family Law Form 12.903(b), Answer to
Petition for Dissolution of Marriage (03/15)
- 82 -
 Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida
Supreme Court Approved Family Law Form 12.902(d), if the case involves a dependent or
minor child(ren).
 Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e), if
the case involves a dependent or minor child(ren). (If you do not know the other party’s income,
you may file this worksheet after his or her financial affidavit has been served on you).
 Marital Settlement Agreement for Dissolution of Marriage with Dependent or Minor
Child(ren), Florida Supreme Court Approved Family Law Form 12.902(f)(1), or Marital
Settlement Agreement for Dissolution of Marriage with Property but No Dependent or
Minor Child(ren), Florida Supreme Court Approved Family Law Form 12.902(f)(2), if you
have reached an agreement on any or all of the issues.
 Notice of Social Security Number, Florida Supreme Court Approved Family Law Form
12.902(j).
 Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or (c).
(This must be filed within 45 days of service of the petition on you, if not filed at the time
you file this answer.)
 Certificate of Compliance with Mandatory Disclosure, Florida Family Law Rules of
Procedure Form 12.932. (This must be filed within 45 days of service of the petition on you,
if not filed at the time you file this answer, unless you and the other party have agreed not
to exchange these documents.)

Parenting and Time-sharing... If you and your spouse are unable to agree on parenting
arrangements and a time-sharing schedule, a judge will decide for you as part of establishing a
Parenting Plan. The judge will decide the parenting arrangements and time-sharing schedule based
on the child(ren)’s best interests. Regardless of whether there is an agreement, the court reserves
jurisdiction to modify issues relating to the minor child(ren).

A parenting course must be completed prior to the entry of a final judgment. You should contact
the clerk, family law intake staff, or judicial assistant about requirements for parenting courses
where you live.

Instructions for Florida Supreme Court Approved Family Law Form 12.903(b), Answer to
Petition for Dissolution of Marriage (03/15)
- 83 -
 Shared Parental Responsibility
 Sole Parental Responsibility
 Supervised Time-Sharing
 No contact
 Parenting Plan
 Parenting Plan Recommendation
 Time-Sharing Schedule

Child Support... The court may order one parent to pay child support to assist the other parent in
meeting the child(ren)’s material needs. Both parents are required to provide financial support,
but one parent may be ordered to pay a portion of his or her support for the child(ren) to the other
parent. Florida has adopted guidelines for determining the amount of child support to be paid.
These guidelines are based on the combined income of both parents and take into account the
financial contributions of both parents and the number of overnights the child(ren) spend with each
parent. You must file a Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form
12.902(b) or (c), and your spouse will be required to do the same. From your financial affidavits, you
should be able to calculate the amount of child support that should be paid using the Child Support
Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e). Because the child
support guidelines take several factors into consideration, change over time, and vary from state to
state, your child support obligation may be more or less than that of other people in seemingly
similar situations.

Alimony... Alimony may be awarded to a spouse if the judge finds that he or she needs it and that
the other spouse has the ability to pay it. If you want alimony, you must request it in writing in a
counterpetition. Florida Supreme Court Approved Family Law Form 12.903(c)(1) (with dependent or
minor child(ren)), or Florida Supreme Court Approved Family Law Form 12.903(c)(2) (no dependent
or minor child(ren)). If you do not request alimony in writing before the final hearing, it is waived
(you may not request it later).

Marital/Nonmarital Assets and Liabilities... Florida law requires an equitable distribution of
marital assets and marital liabilities. “Equitable” does not necessarily mean “equal.” Many factors,
including child support, any parenting plan and time-sharing schedule, and alimony awards, may
lead the court to make an unequal (but still equitable) distribution of assets and liabilities.
Nonmarital assets and nonmarital liabilities are those assets and liabilities which the parties agree
or the court determines belong to, or are the responsibility of, only one of the parties. If the parties
agree or the court finds an asset or liability to be nonmarital, the judge will not consider it when
distributing marital assets and liabilities.

Temporary Relief... If you need temporary relief regarding temporary use of assets, temporary
responsibility for liabilities, parental responsibility and time-sharing with child(ren), temporary child
support, or temporary alimony, you may file a Motion for Temporary Support and Time-Sharing

Instructions for Florida Supreme Court Approved Family Law Form 12.903(b), Answer to
Petition for Dissolution of Marriage (03/15)
- 84 -
with Dependent or Minor Child(ren), Florida Supreme Court Approved Family Law Form 12.947(a),
or, if there are no dependent or minor child(ren), Motion for Temporary Support with No
Dependent or Minor Child(ren), Florida Supreme Court Approved Family Law Form 12.947(c). For
more information, see the instructions for these forms.

Marital Settlement Agreement... If you and your spouse are able to reach an agreement on any or
all of the issues, you should file a Marital Settlement Agreement for Dissolution of Marriage with
Dependent or Minor Child(ren), Florida Supreme Court Approved Family Law Form 12.902(f)(1), or
Marital Settlement Agreement for Dissolution of Marriage with No Dependent or Minor
Child(ren), Florida Supreme Court Approved Family Law Form 12.902(f)(2). Both parties must sign
this agreement before a notary public or deputy clerk. Any issues on which you are unable to agree
will be considered contested and settled by the judge at the final hearing.

Final Judgment Form... These family law forms contain a Final Judgment of Dissolution of Marriage
with Dependent or Minor Child(ren), Florida Supreme Court Approved Family Law Form
12.990(c)(1), and Final Judgment of Dissolution of Marriage with Property but No Dependent or
Minor Child(ren), Florida Supreme Court Approved Family Law Form 12.990(c)(2), which the judge
may use if your case is contested. If you and your spouse reach an agreement on all of the issues,
the judge may use Final Judgment of Dissolution of Marriage with Dependent or Minor Child(ren)
(Uncontested), Florida Supreme Court Approved Family Law Form 12.990(b)(1), Final Judgment of
Dissolution of Marriage with Property but No Dependent or Minor Child(ren) (Uncontested),
Florida Supreme Court Approved Family Law Form 12.990(b)(2), or Final Judgment of Dissolution of
Marriage with No Property and No Dependent or Minor Child(ren), Florida Supreme Court
Approved Family Law Form 12.990(b)(3). You should check with the clerk, family law intake staff, or
judicial assistant to see if you need to bring a final judgment with you to the hearing. If so, you
should type or print the heading, including the circuit, county, case number, division, and the
parties’ names, and leave the rest blank for the judge to complete at your hearing or trial.

Nonlawyer... Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer
helps you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer,
Florida Family Law Rules of Procedure Form 12.900(a), before he or she helps you. A nonlawyer
helping you fill out these forms also must put his or her name, address, and telephone number on
the bottom of the last page of every form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.903(b), Answer to
Petition for Dissolution of Marriage (03/15)
- 85 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
,
Petitioner,

and

,
Respondent.

ANSWER TO PETITION FOR DISSOLUTION OF MARRIAGE

I, {full legal name} ____________________________________________, Respondent, being sworn,
certify that the following information is true:

1. I agree with Petitioner as to the allegations raised in the following numbered paragraphs in the
Petition and, therefore, admit those allegations: {indicate section and paragraph number}
___________________________________________________________________________
___________________________________________________________________________

2. I disagree with Petitioner as to the allegations raised in the following numbered paragraphs in
the Petition and, therefore, deny those allegations: {indicate section and paragraph number}
____________________________________________________________________
___________________________________________________________________________

3. I currently am unable to admit or deny the allegations raised in the following paragraphs due to
lack of information: {indicate section and paragraph number} ___________________
___________________________________________________________________________

4. If this case involves a dependent or minor child(ren), a completed Uniform Child Custody
Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida Supreme Court Approved Family
Law Form 12.902(d), is filed with this answer.

5. If this case involves a dependent or minor child(ren), a completed Child Support Guidelines
Worksheet, Florida Family Law Rules of Procedure Form 12.902(e), is [choose one only]
_____ filed with this answer or _____ will be filed after the other party serves his or her financial
affidavit.

6. If necessary a completed Notice of Social Security Number, Florida Supreme Court Approved
Family Law Form 12.902(j), is filed with this answer.

7. A completed Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form
12.902(b) or (c), [Choose only one] _____ is filed with this answer or _____ will be timely filed.

Florida Supreme Court Approved Family Law Form 12.903(b), Answer to Petition for Dissolution
of Marriage (03/15)
- 86 -
I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand
delivered to the person(s) listed below on {date} _____________________.

Petitioner or his/her attorney:
Name:
Address:
City, State, Zip:
Fax Number:
Designated E-mail Address(es):__________________
__________________________________________

Dated:
___________________________________________
Signature of Respondent
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es):_______________
_______________________________________

STATE OF FLORIDA
COUNTY OF __________________________

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

[Print, type, or stamp commissioned name of notary or clerk.]
Personally known
Produced identification
Type of identification produced

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the Respondent.
This form was completed with the assistance of:
{name of individual} _________________________________________________________________,
{name of business} __________________________________________________________________,

Florida Supreme Court Approved Family Law Form 12.903(b), Answer to Petition for Dissolution
of Marriage (03/15)
- 87 -
{address} __________________________________________________________________________,
{city} ______________, {state} _____,{zip code}___________,{telephone number} ________________.

Florida Supreme Court Approved Family Law Form 12.903(b), Answer to Petition for Dissolution
of Marriage (03/15)
- 88 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.903(c)(1)
ANSWER TO PETITION AND COUNTERPETITION FOR DISSOLUTION OF
MARRIAGE WITH DEPENDENT OR MINOR CHILD(REN) (03/15)

When should this form be used?

This form should be used when you are responding to a petition for dissolution of marriage with
dependent or minor child(ren) and you are asking the court for something not contained in the petition.
The answer portion of this form is used to admit or deny the allegations contained in the petition, and
the counterpetition portion of this form is used to ask for whatever you want the court to do for you.

This form should be typed or printed in black ink. After completing this form, you should sign the form
before a notary public or deputy clerk. You should file the original with the clerk of the circuit court in
the county where the petition was filed and keep a copy for your records. The person filing the petition
in a dissolution of marriage proceeding is also referred to as the petitioner and his or her spouse as the
respondent. The person filing a counterpetition is also referred to as the counterpetitioner and his or
her spouse as the counterrespondent.

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?

You have 20 days to answer after being served with your spouse’s petition. A copy of this form must be
mailed, e-mailed, or hand delivered to your spouse. After you file an answer and counterpetition your
case will then generally proceed as follows:

The other party is required to answer your counterpetition within 20 days using an Answer to
Counterpetition, Florida Supreme Court Approved Family Law Form 12.903(d).

UNCONTESTED... Your dissolution is uncontested if you and your spouse agree on all issues raised in the
petition and the counterpetition. If this is the case, and you and the other party have complied with
mandatory disclosure and filed all of the required papers, either party may call the clerk, family law
intake staff, or judicial assistant to set a final hearing. If you request the hearing, you must notify the

Instructions for Florida Supreme Court Approved Family Law Form 12.903(c)(1), Answer to
Petition and Counterpetition for Dissolution of Marriage with Dependent or Minor Child(ren)
(03/15)
- 89 -
other party of the hearing by using a Notice of Hearing (General), Florida Supreme Court Approved
Family Law Form 12.923, or other appropriate notice of hearing form.

CONTESTED... Your dissolution is contested if you and your spouse disagree on any issue raised in the
petition or counterpetition. If you are unable to settle the disputed issues, either party may file a Notice
for Trial, Florida Supreme Court Approved Family Law Form 12.924, after you have complied with
mandatory disclosure and filed all of the required papers. Some circuits may require the completion of
mediation before a final hearing may be set. You should contact the clerk, family law intake staff, or
judicial assistant for instructions on how to set your case for trial (final hearing).

Where can I look for more information?

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Special notes...

With this form, you must also file the following:

 Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida Supreme

Instructions for Florida Supreme Court Approved Family Law Form 12.903(c)(1), Answer to
Petition and Counterpetition for Dissolution of Marriage with Dependent or Minor Child(ren)
(03/15)
- 90 -
Court Approved Family Law Form 12.902(d)
 Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e). (If
you do not know the other party’s income, you may file this worksheet after his or her financial
affidavit has been served on you.)
 Affidavit of Corroborating Witness, Florida Supreme Court Approved Family Law Form 12.902(i)
OR photocopy of current Florida driver’s license, Florida identification card, or voter’s
registration card (issue date of copied document must be at least six months before date case is
actually filed with the clerk of the circuit court).
 Marital Settlement Agreement for Dissolution of Marriage with Dependent or Minor
Child(ren), Florida Supreme Court Approved Family Law Form 12.902(f)(1), if you have reached
an agreement on any or all of the issues.
 Parenting Plan, Florida Supreme Court Approved Family Law Form 12.9.995(a), Safety-Focused
Parenting Plan, Form 12.995(b), or Relocation/Long-Distance Parenting Plan, Form 12.995(c).
If the parents have reached an agreement, a signed and notarized Parenting Plan should be
attached. If the parents have not reached an agreement, a proposed Parenting Plan may be
filed.
 Notice of Social Security Number, Florida Supreme Court Approved Family Law Form 12.902(j).
 Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or (c).
(This must be filed within 45 days of service of the petition on you, if not filed at the time you
file this answer.)
 Certificate of Compliance with Mandatory Disclosure, Florida Family Law Rules of Procedure
Form 12.932. (This must be filed within 45 days of service of the petition on you, if not filed at
the time you file this answer, unless you and the other party have agreed not to exchange these
documents.)

Parenting Plan and Time-Sharing... If you and your spouse are unable to agree on parenting
arrangements and a time-sharing schedule, a judge will decide for you as part of establishing a Parenting
Plan. The judge will decide the parenting arrangements and time-sharing schedule based on the
child(ren)’s best interests. Regardless of whether there is an agreement, the court reserves jurisdiction
to modify issues relating to the minor child(ren).

Instructions for Florida Supreme Court Approved Family Law Form 12.903(c)(1), Answer to
Petition and Counterpetition for Dissolution of Marriage with Dependent or Minor Child(ren)
(03/15)
- 91 -
 Shared Parental Responsibility
 Sole Parental Responsibility
 Supervised Time-Sharing
 No contact
 Parenting Plan
 Parenting Plan Recommendation
 Time-Sharing Schedule

Child Support... The court may order one parent to pay child support to assist the other parent in
meeting the child(ren)’s material needs. Both parents are required to provide financial support, but
one parent may be ordered to pay a portion of his or her support for the child(ren) to the other parent.
Florida has adopted guidelines for determining the amount of child support to be paid. These guidelines
are based on the combined income of both parents and take into account the financial contributions of
both parents. You must file a Family Law Financial Affidavit, Florida Family Law Rules of Procedure
Form 12.902(b) or (c), and your spouse will be required to do the same. From your financial affidavits,
you should be able to calculate the amount of child support that should be paid using the Child Support
Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e). Because the child
support guidelines take several factors into consideration, change over time, and vary from state to
state, your child support obligation may be more or less than that of other people in seemingly similar
situations.

Alimony... Alimony may be awarded to a spouse if the judge finds that he or she has an actual need for
it and that the other spouse has the ability to pay. If you want alimony, you must request it in writing
in your counterpetition. If you do not request alimony in writing before the final hearing, it is waived
(you may not request it later). You may request permanent alimony, bridge-the-gap alimony,
durational alimony, lump sum alimony, or rehabilitative alimony.

Marital/Nonmarital Assets and Liabilities... Florida law requires an equitable distribution of marital
assets and marital liabilities. Equitable does not necessarily mean equal. Many factors, including child
support, time-sharing and alimony awards, may lead the court to make an unequal (but still equitable)
distribution of assets and liabilities. Nonmarital assets and nonmarital liabilities are those assets and
liabilities which the parties agree or the court determines belong to, or are the responsibility of, only
one of the parties. If the parties agree or the court finds an asset or liability to be nonmarital, the judge
will not consider it when distributing marital assets and liabilities.

Parenting Plan… In all cases involving minor or dependent child(ren), a Parenting Plan shall be approved
or established by the court. If you and your spouse have reached an agreement, you should file
Parenting Plan, Florida Supreme Court Approved Family Law Form 12.995(a), 12.995(b), or 12.995(c),
which addresses the time-sharing schedule for the child(ren). If you have not reached an agreement, a
proposed Parenting Plan may be filed. If you and your spouse cannot agree, a Parenting Plan will be
established by the court.

Instructions for Florida Supreme Court Approved Family Law Form 12.903(c)(1), Answer to
Petition and Counterpetition for Dissolution of Marriage with Dependent or Minor Child(ren)
(03/15)
- 92 -
Temporary Relief... If you need temporary relief regarding temporary use of assets, temporary
responsibility for liabilities, parental responsibility and time-sharing with child(ren), temporary child
support, or temporary alimony, you may file a Motion for Temporary Support and Time-Sharing with
Dependent or Minor Child(ren), Florida Supreme Court Approved Family Law Form 12.947(a). For more
information, see the instructions for that form.

Marital Settlement Agreement... If you and your spouse are able to reach an agreement on any or all of
the issues, you should file a Marital Settlement Agreement for Dissolution of Marriage with Dependent
or Minor Child(ren), Florida Supreme Court Approved Family Law Form 12.902(f)(1). Both of you must
sign this agreement before a notary public or deputy clerk. Any issues on which you are unable to
agree will be considered contested and settled by the judge at the final hearing.

Final Judgment Form... These family law forms contain a Final Judgment of Dissolution of Marriage
with Dependent or Minor Child(ren), Florida Supreme Court Approved Family Law Form 12.990(c)(1),
which the judge may use if your case is contested. If you and your spouse reach an agreement on all of
the issues, the judge may use a Final Judgment of Dissolution of Marriage with Dependent or Minor
Child(ren) (Uncontested), Florida Supreme Court Approved Family Law Form 12.990(b)(1). You should
check with the clerk, family law intake staff, or judicial assistant to see if you need to bring a final
judgment with you to the hearing. If so, you should type or print the heading, including the circuit,
county, case number, division, and the parties’ names, and leave the rest blank for the judge to
complete at your hearing or trial.

Nonlawyer... Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps
you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida
Family Law Rules of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill
out these forms also must put his or her name, address, and telephone number on the bottom of the
last page of every form he or she helps you complete.

Case No.:
Division:
In re: the Marriage of:

,
Husband,

and

,
Wife.

ANSWER TO PETITION AND COUNTERPETITION FOR DISSOLUTION
OF MARRIAGE WITH DEPENDENT OR MINOR CHILD(REN)
I, {full legal name} , being sworn, certify that the
following information is true:

2. I disagree with the allegations raised in the following numbered paragraphs in the Petition and,
therefore, deny those allegations: {indicate section and paragraph number} ______________
.

3. I currently am unable to admit or deny the following paragraphs due to lack of information:
{indicate section and paragraph number} _________________________________________
.

COUNTERPETITION FOR DISSOLUTION OF MARRIAGE WITH MINOR CHILD(REN)

1. JURISDICTION/RESIDENCE
_____ Husband _____ Wife _____Both has (have) lived in Florida for at least 6 months before the filing
of this Petition for Dissolution of Marriage.

2. Husband _____ is or _____ is not a member of the military service.
Wife _____ is or _____ is not a member of the military service.

3. MARRIAGE HISTORY
Date of marriage: {month, day, year} ____________________________________________
Date of separation: {month, day, year} _____________________ (_____Indicate if approximate)

4. DEPENDENT OR MINOR CHILD(REN)
[Indicate all that apply]
a. _____The wife is pregnant. Baby is due on: {date}

b. _____The minor (under 18) child(ren) common to both parties are:

Name Birth date
_________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

c. _____The minor child(ren) born or conceived during the marriage who are not common to
both parties are:

Name Birth date
___________________________________________________________________________
____________________________________________________________________________

The birth father(s) of the above minor child(ren) is (are) {name and address}

d. _____ The child(ren) common to both parties who are 18 or older but who are dependent
upon the parties due to a mental or physical disability are:

Name Birth date
______________________________________________________________________________
______________________________________________________________________________

5. A completed Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit Florida
Supreme Court Approved Family Law Form 12.902(d), is filed with this counterpetition. (You
must complete and attach this form in a dissolution of marriage with minor child(ren).

6. A completed Notice of Social Security Number, Florida Supreme Court Approved Family Law
Form 12.902(j), is filed with this counterpetition.

7. A completed Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form
12.902(b) or (c) _____ is filed or _____ will be timely filed.

8. This counterpetition for dissolution of marriage should be granted because:

a. _____The marriage is irretrievably broken.

Florida Supreme Court Approved Family Law Form 12.903(c)(1), Answer to Petition and
Counterpetition for Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
- 95 -
OR

b. _____One of the parties has been adjudged mentally incapacitated for a period of 3 years
prior to the filing of this counterpetition. A copy of the Judgment of Incapacity is attached.
SECTION I. MARITAL ASSETS AND LIABILITIES

1. ____There are no marital assets or liabilities.

a. _____All marital assets and liabilities have been divided by a written agreement between
the parties, which is attached to be incorporated into the final judgment of dissolution of
marriage. (The parties may use Marital Settlement Agreement for Dissolution of Marriage
with Dependent or Minor Child(ren), Florida Supreme Court Approved Family Law Form
12.902(f)(1)).

b. _____The Court should determine how the assets and liabilities of this marriage are to be
distributed, under section 61.075, Florida Statutes.

SECTION II. SPOUSAL SUPPORT (ALIMONY)

1. _____Husband _____Wife forever gives up his/her right to spousal support (alimony) from the
other spouse.

2. _____Husband _____Wife requests that the Court order the other spouse to pay the following
spousal support (alimony) and claims that he or she has an actual need for the support that he
or she is requesting and that the other spouse has the ability to pay that support. Spousal
support (alimony) is requested in the amount of $______________ every _____ week _____
other week _____ month, beginning {date}______________________ and continuing until {date
or event} ______________________________________________________________________.
{Explain why the Court should order _____Husband _____Wife to pay, and any specific request(s) for
type of alimony (temporary, permanent, bridge-the-gap, durational, rehabilitative, and/or lump sum}):

Florida Supreme Court Approved Family Law Form 12.903(c)(1), Answer to Petition and
Counterpetition for Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
- 96 -
3. _____Other provisions relating to alimony including any tax treatment and consequences:
______________________________________________________________________________
_______________________________________________________________________ .

4. ____Husband ____ Wife requests life insurance on the other spouse’s life, provided by that spouse,
to secure such support.

SECTION III. PARENTING PLAN ESTABLISHING PARENTAL RESPONSIBILITY AND TIME-SHARING

1. The minor child(ren) currently reside(s) with _____ Mother _____ Father _____ Other: {explain}
_____________________________________________________________________________

2. Parental Responsibility. It is in the child(ren)’s best interests that parental responsibility be:
[Choose only one]
a. _____shared by both Father and Mother.

b. _____awarded solely to _____ Father _____ Mother. Shared parental responsibility would
be detrimental to the child(ren) because: ________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________.

3. Parenting Plan and Time-Sharing. It is in the best interests of the child(ren) that the family be
ordered to comply with a Parenting Plan that _____ includes _____does not include parental
time-sharing with the child(ren). The _____ Husband _____ Wife states that it is in the best
interests of the child(ren) that:
[Choose only one]
a. _____The attached proposed Parenting Plan should be adopted by the court. The parties
_____have _____ have not agreed to the Parenting Plan.

b. _____The court should establish a Parenting Plan with the following provisions:
_____ No time-sharing for the _____ Father _____ Mother.
_____ Limited time-sharing with the _____ Father _____ Mother.
_____ Supervised time-sharing for the _____ Father _____ Mother.
_____ Supervised or third-party exchange of the child(ren).
_____ Time-sharing as follows: ______________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Explain why this request is in the best interests of the child(ren):

1. _____Husband _____Wife requests that the Court award child support as determined by
Florida’s child support guidelines, section 61.30, Florida Statutes. A completed Child Support
Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e), is, or will be filed.
Such support should be ordered retroactive to:

a. _____ the date of separation {date} ___________
b. _____the date of the filing of this petition.
c. _____other {date} ________________________{explain} _________________________
________________________________________________________________________

2. _____Husband _____Wife requests that the Court award child support to be paid beyond the
age of 18 years because:

a. _____the following child(ren) {name(s)} __________________________________________
___________________________________________________________________________
is (are) dependent because of a mental or physical incapacity which began before the age of 18.
{explain} ________________________________________________________________

b. _____the following child(ren) {name(s)} __________________________________________
is (are) dependent in fact; is (are) in high school, and are between the ages of 18 and 19;
said child(ren) is (are) performing in good faith with reasonable expectation of graduation
before the age of 19.

3. _____Husband _____Wife requests that the Court award a child support amount that is more
than or less than Florida’s child support guidelines and understands that a Motion to Deviate
from Child Support Guidelines, Florida Supreme Court Approved Family Law Form 12.943, must
be filed before the Court will consider this request.

4. _____Husband _____Wife requests that medical/dental insurance for the minor child(ren) be
provided by:
[Choose only one]
a. _____Husband.
b. _____Wife.

5. _____Husband _____Wife requests that uninsured medical/dental expenses for the child(ren)
be paid:
[Choose only one]
a. _____ by Husband.

Florida Supreme Court Approved Family Law Form 12.903(c)(1), Answer to Petition and
Counterpetition for Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
- 98 -
b. _____ by Wife.
c. _____ by Husband and Wife each paying one-half.
d. _____ according to the percentages in the Child Support Guidelines Worksheet, Florida
Family Law Rules of Procedure Form 12.902(e).
e. _____ Other {explain}:
__________________________________________________________

6. _____ Husband _____Wife requests that life insurance to secure child support be provided by:

a. _____Husband.
b. _____ Wife.
c. _____ Both.

SECTION V. OTHER

1. Wife requests to be known by her former name, which was {full legal name} :
_____________________________________________________________________________

2. Other relief {specify}: ____________________________________________________________

SECTION VI. REQUEST
(This section summarizes what you are asking the Court to include in the final judgment of dissolution of
marriage.)
I request that the Court enter an order dissolving the marriage and:
[Indicate all that apply]
1. _____ distributing marital assets and liabilities as requested in Section I of this petition;
2. _____ awarding spousal support (alimony) as requested in Section II of this petition;
3. _____ adopting or establishing a Parenting Plan containing provisions for parental responsibility
and time-sharing for the dependent or minor child(ren) common to both parties, as requested in
Section III of this petition;
4. _____ establishing child support for the dependent or minor child(ren) common to both parties,
as requested in Section IV of this petition;
5. _____ restoring Wife’s former name as requested in Section V of this petition;
6. _____ awarding other relief as requested in Section V of this petition; and any other terms the
Court deems necessary.

I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-
delivered to the person(s) listed below on {date} ___________________________.

Other party or his/her attorney:
Name:
Address:

Florida Supreme Court Approved Family Law Form 12.903(c)(1), Answer to Petition and
Counterpetition for Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
- 100 -
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
answer and counterpetition and that the punishment for knowingly making a false statement includes
fines and/or imprisonment.

_____________________________________________
Signature of _____ Husband _____ Wife
Printed Name: _______________________________
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es): ___________________
_____________________________________________

STATE OF FLORIDA
COUNTY OF __________________________

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

{Print, type, or stamp commissioned name of notary or clerk.}
__ Personally known
__ Produced identification
Type of identification produced _________________________________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Husband ( ) Wife
This form was completed with the assistance of:
{name of individual} _________________________________________________________________,
{name of business} __________________________________________________________________,
{address} __________________________________________________________________________,
{city} ______________, {state} _____,{zip code}___________,{telephone number} ________________.

Florida Supreme Court Approved Family Law Form 12.903(c)(1), Answer to Petition and
Counterpetition for Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
- 101 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.903(c)(2)
ANSWER TO PETITION AND COUNTERPETITION FOR DISSOLUTION OF
MARRIAGE WITH PROPERTY BUT NO DEPENDENT OR MINOR
CHILD(REN) (03/15)

When should this form be used?

This form should be used when you are responding to a petition for dissolution of marriage with
property but no dependent or minor child(ren) and you are asking the court for something not
contained in the petition. The answer portion of this form is used to admit or deny the allegations
contained in the petition, and the counterpetition portion of this form is used to ask for whatever you
want the court to do for you.

This form should be typed or printed in black ink. After completing this form, you should sign the form
before a notary public or deputy clerk. You should file the original with the clerk of the circuit court in
the county where the petition was filed and keep a copy for your records. The person filing the petition
in a dissolution of marriage proceeding is also referred to as the petitioner and his or her spouse as the
respondent. The person filing the counterpetition is referred to as the counterpetitioner and his or her
spouse as the counterrespondent.

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?

Instructions for Florida Supreme Court Approved Family Law Form 12.903(c)(2), Answer to
Petition and Counterpetition for Dissolution of Marriage with Property but No Dependent or
Minor Child(ren) (03/15)
- 102 -
Your spouse is required to answer your counterpetition within 20 days using an Answer to
Counterpetition, Florida Supreme Court Approved Family Law Form 12.903(d).

CONTESTED... Your dissolution is contested if you and your spouse disagree on any issue raised in the
petition or counterpetition. If you are unable to settle the disputed issues, either spouse may file a
Notice for Trial, Florida Supreme Court Approved Family Law Form 12.924, after you have complied with
mandatory disclosure and filed all of the required papers. Some circuits may require the completion of
mediation before a final hearing may be set. You should contact the clerk, family law intake staff, or
judicial assistant for instructions on how to set your case for trial (final hearing).

Where can I look for more information?

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

With this form, you must also file the following:

 Affidavit of Corroborating Witness, Florida Supreme Court Approved Family Law Form 12.902(i) OR
photocopy of current Florida driver’s license, Florida identification card, or voter’s registration card
(issue date of copied document must be at least six months before date case is actually filed with
the clerk of the circuit court).
 Marital Settlement Agreement for Dissolution of Marriage with No Dependent or Minor
Child(ren), Florida Supreme Court Approved Family Law Form 12.902(f)(2), if you have reached an
agreement on any or all of the issues.
 Notice of Social Security Number, Florida Supreme Court Approved Family Law Form 12.902(j).
 Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or (c). (This
must be filed within 45 days of service of the petition on you, if not filed at the time you file this
answer.)
 Certificate of Compliance with Mandatory Disclosure, Florida Family Law Rules of Procedure Form
12.932. (This must be filed within 45 days of service of the petition on you, if not filed at the time
you file this answer, unless you and the other party have agreed not to exchange these documents.)

Alimony... Alimony may be awarded to one spouse if the judge finds that he or she has an actual need
for it and also finds that the other spouse has the ability to pay. If you want alimony, you must request
it in writing in your counterpetition. If you do not request alimony in writing before the final hearing,
it is waived (you may not request it later). You may request permanent alimony, bridge-the-gap
alimony, durational alimony, lump sum alimony, or rehabilitative alimony.

Marital/Nonmarital Assets and Liabilities... Florida law requires an equitable distribution of marital
assets and marital liabilities. Equitable does not necessarily mean equal. Many factors, including
alimony awards, may lead the court to make an unequal (but still equitable) distribution of assets and
liabilities. Nonmarital assets and nonmarital liabilities are those assets and liabilities which the parties
agree or the court determines belong to, or are the responsibility of, only one of the parties. If the
parties agree or the court finds an asset or liability to be nonmarital, the judge will not consider it when
distributing marital assets and liabilities.

Instructions for Florida Supreme Court Approved Family Law Form 12.903(c)(2), Answer to
Petition and Counterpetition for Dissolution of Marriage with Property but No Dependent or
Minor Child(ren) (03/15)
- 104 -
you must sign this agreement before a notary public. Any issues on which you are unable to agree will
be considered contested and settled by the judge at the final hearing.

Final Judgment Forms... These family law forms contain a Final Judgment of Dissolution of Marriage
with Property but No Dependent or Minor Child(ren), Florida Supreme Court Approved Family Law
Form 12.990(c)(2), which the judge may use if your case is contested. If you and your spouse reach an
agreement on all of the issues, the judge may use a Final Judgment of Dissolution of Marriage with
Property but No Dependent or Minor Child(ren) (Uncontested), Florida Supreme Court Approved
Family Law Form 12.990(b)(2). You should check with the clerk, family law intake staff, or judicial
assistant to see if you need to bring a final judgment with you to the hearing. If so, you should type or
print the heading, including the circuit, county, case number, division, and the parties’ names, and leave
the rest blank for the judge to complete at your hearing or trial.

Nonlawyer... Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps
you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida
Family Law Rules of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill
out these forms also must put his or her name, address, and telephone number on the bottom of the
last page of every form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.903(c)(2), Answer to
Petition and Counterpetition for Dissolution of Marriage with Property but No Dependent or
Minor Child(ren) (03/15)
- 105 -
IN THE CIRCUIT COURT OF THE _____________________ JUDICIAL CIRCUIT,
IN AND FOR ______________________________ COUNTY, FLORIDA

Case No:________________________
Division:________________________
In re: the Marriage of

_________________________________,
Husband,
and

_________________________________,
Wife.

ANSWER TO PETITION AND COUNTERPETITION FOR DISSOLUTION OF
MARRIAGE WITH PROPERTY BUT NO DEPENDENT OR MINOR
CHILD(REN)

I, {full legal name} ______________________________________________________, being sworn,
certify that the following information is true:

ANSWER TO PETITION
1. I agree with the allegations raised in the following numbered paragraphs in the Petition and,
therefore, admit those allegations: {indicate section and paragraph number}
_______________________________________________________________________________
_______________________________________________________________________________.

2. I disagree with the allegations raised in the following numbered paragraphs in the Petition and,
therefore, deny those allegations: {indicate section and paragraph number}
_______________________________________________________________________________
_______________________________________________________________________________.
3. I currently am unable to admit or deny the following paragraphs due to lack of information: {indicate
section and paragraph number}
_______________________________________________________________________________
_______________________________________________________________________________.

COUNTERPETITION FOR DISSOLUTION OF MARRIAGE WITH PROPERTY BUT NO
DEPENDENT OR MINOR CHILD(REN)

1. JURISDICTION/RESIDENCE
_____ Husband _____ Wife _____ Both has (have) lived in Florida for at least 6 months before the filing
of this Petition for Dissolution of Marriage.

Florida Supreme Court Approved Family Law Form 12.903(c)(2), Answer to Petition and
Counterpetition for Dissolution of Marriage with Property but No Dependent or Minor
Child(ren) (03/15)
- 106 -
2. Petitioner _____ is or _____ is not a member of the military service.
Respondent _____ is or _____ is not a member of the military service.

3. MARRIAGE HISTORY
Date of marriage: {month, day, year} _______________________
Date of separation: {month, day, year}______________________(____Indicate if approximate)
Place of marriage: {county, state, country}____________________________________________

4. THERE ARE NO MINOR (UNDER 18) OR DEPENDENT CHILD(REN) COMMON TO BOTH PARTIES AND
THE WIFE IS NOT PREGNANT.

5. A completed Notice of Social Security Number, Florida Supreme Court Approved Family Law Form
12.902(j), is filed with this counterpetition.

6. This counterpetition for dissolution of marriage should be granted because:

a. _____ The marriage is irretrievably broken.

b. _____ One of the parties has been adjudged mentally incapacitated for a period of 3 years prior
to the filing of this counterpetition. A copy of the Judgment of Incapacity is attached.

SECTION I. MARITAL ASSETS AND LIABILITIES
[Choose only one]
1. _____ There are no marital assets or liabilities.

b. _____ The Court should determine how the assets and liabilities of this marriage are to be
distributed, under section 61.075, Florida Statutes.

c. _____ Husband _____Wife should be awarded an interest in the other spouse’s property
because: ____________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
____________________________________________________________________________.

1. _____ Husband _____Wife forever gives up his/her right to spousal support (alimony) from the
other spouse.
OR
2. _____ Husband _____Wife requests that the Court order the other spouse to pay the following
spousal support (alimony) and claims that he or she has an actual need for the support that he or
she is requesting and that the other spouse has the ability to pay that support. Spousal support
(alimony) is requested in the amount of $_______________ every _____ week _____ other week
_____ month, beginning {date} _______________________ and continuing until {date or event}
______________________________________________________________________________
_______________________________________________________________________________.
Explain why the Court should order _____Husband _____Wife to pay, and any specific request(s) for
type of alimony (temporary, permanent, bridge-the-gap, durational, rehabilitative, and/or lump sum):
_____________________________________________________________________________________
___________________________________________________________________________
_____________________________________________________________________________________
__________________________________________________________________________ .

3. _____Other provisions relating to alimony including any tax treatment or consequences:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________ .

4. _____Husband _____ Wife requests life insurance on the other spouse’s life, provided by that
spouse, to secure such support

SECTION III. OTHER
1. Wife requests to be known by her former name, which was {full legal name}
_____________________________________________________________.

2. Other relief {specify}:
_______________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

SECTION IV. REQUEST (This section summarizes what you are asking the Court to include in the final
judgment of dissolution of marriage.)

1. ____ distributing marital assets and liabilities as requested in Section I of this petition;
2. ____ awarding spousal support (alimony) as requested in Section II of this petition;
3. ____ restoring Wife’s former name as requested in Section III of this petition;
4. ____ awarding other relief as requested in Section III of this petition; and any other terms the
Court deems necessary.

I certify that a copy of this document was _____ mailed _____ faxed and mailed
( ) e-mailed ( ) hand delivered to the person(s) listed below on {date}________________________.

Other party or his/her attorney:
Printed Name: ________________________________
Address: _____________________________________
City, State, Zip: ________________________________
Fax Number: ____________________________________
Designated E-mail Address(es):______________________

I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
answer and counterpetition and that the punishment for knowingly making a false statement includes
fines and/or imprisonment.

Dated: ______________________ ____________________________________________
Signature of ( ) Husband ( )Wife
Printed Name: ______________________________
Address:_____________________________________
City, State, Zip:________________________________
Telephone Number:___________________________
Fax Number: _________________________________
Designated E-mail Address(es): __________________
____________________________________________

STATE OF FLORIDA
COUNTY OF ____________________

Sworn to or affirmed and signed before me on ___________ by _______________________________.

____________________________________________
NOTARY PUBLIC or DEPUTY CLERK
____________________________________________
{Print, type, or stamp commissioned name of notary or deputy clerk.}
____ Personally known
____ Produced identification
____ Type of identification produced ________________________________

Florida Supreme Court Approved Family Law Form 12.903(c)(2), Answer to Petition and
Counterpetition for Dissolution of Marriage with Property but No Dependent or Minor
Child(ren) (03/15)
- 109 -
IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Husband ( ) Wife
This form was completed with the assistance of:
{name of individual} _________________________________________________________________,
{name of business} __________________________________________________________________,
{address} __________________________________________________________________________,
{city} ______________, {state} _____,{zip code}___________,{telephone number} ________________.

Florida Supreme Court Approved Family Law Form 12.903(c)(2), Answer to Petition and
Counterpetition for Dissolution of Marriage with Property but No Dependent or Minor
Child(ren) (03/15)
- 110 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.903(c)(3)
ANSWER TO PETITION AND COUNTERPETITION FOR DISSOLUTION OF
MARRIAGE WITH NO DEPENDENT OR MINOR CHILD(REN) OR PROPERTY
(03/15)
When should this form be used?

This form should be used when you are responding to a petition for dissolution of marriage with no
dependent or minor child(ren) or property and you are asking the court for something not contained in
the petition. The answer portion of this form is used to admit or deny the allegations contained in the
petition, and the counterpetition portion of this form is used to ask for whatever you want the court to
do for you such as restoring your former name.

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?

You have 20 days to answer after being served with the other party’s petition. A copy of this form must
be mailed, e-mailed, or hand delivered to the other party. After you file an answer and counterpetition
your case will then generally proceed as follows:

The other party is required to answer your counterpetition within 20 days using an Answer to
Counterpetition, Florida Supreme Court Approved Family Law Form 12.903(d).

CONTESTED... Your dissolution is contested if you and your spouse disagree on any issues raised in the
petition or counterpetition. If you are unable to settle the disputed issues, either party may file a Notice
for Trial, Florida Supreme Court Approved Family Law Form 12.924, after you have complied with
mandatory disclosure and filed all of the required papers. Some circuits may require the completion of
mediation before a final hearing may be set. You should contact the clerk, family law intake staff, or
judicial assistant for instructions on how to set your case for trial (final hearing).

Where can I look for more information?

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Special notes...

With this form, you must also file the following:

 Affidavit of Corroborating Witness, Florida Supreme Court Approved Family Law Form
12.902(i) OR photocopy of current Florida driver’s license, Florida identification card, or voter’s

Instructions for Florida Supreme Court Approved Family Law Form 12.903(c)(3), Answer to
Petition and Counterpetition for Dissolution of Marriage with No Dependent or Minor
Child(ren) or Property (03/15)
- 112 -
registration card (issue date of copied document must be at least six months before date case is
actually filed with the clerk of the circuit court).
 Notice of Social Security Number, Florida Supreme Court Approved Family Law Form 12.902(j).
 Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or (c).
(This must be filed within 45 days of service of the petition on you, if not filed at the time you
file this answer.)
 Certificate of Compliance with Mandatory Disclosure, Florida Family Law Rules of Procedure
Form 12.932. (This must be filed within 45 days of service of the petition on you, if not filed at
the time you file this answer, unless you and the other party have agreed not to exchange these
documents.)

Alimony... By using this form, you are forever giving up your rights to spousal support (alimony) from
petitioner. Alimony may be awarded to a spouse if the judge finds that he or she needs it and that the
other spouse has the ability to pay it. If you want alimony, you must request it in writing in an
appropriate answer and counterpetition (see the other answer and counterpetition forms included in
these forms for the appropriate form).

Marital/Nonmarital Assets and Liabilities... By using this form, you are stating that there are no marital
assets and/or liabilities.

Final Judgment Form... These family law forms contain a Final Judgment of Dissolution of Marriage
with No Property or Minor Child(ren) (Uncontested), Florida Supreme Court Approved Family Law
Form 12.990(b)(3). You should check with the clerk, family law intake staff, or judicial assistant to see if
you need to bring a final judgment with you to the hearing. If so, you should type or print the heading,
including the circuit, county, case number, division, and the parties’ names, and leave the rest blank for
the judge to complete at your hearing or trial.

Nonlawyer... Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps
you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida
Family Law Rules of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill
out these forms also must put his or her name, address, and telephone number on the bottom of the
last page of every form he or she helps you complete.

Case No.:
Division:
,
Husband,

and

,
Wife.

ANSWER TO PETITION AND COUNTERPETITION FOR DISSOLUTION OF
MARRIAGE WITH NO DEPENDENT OR MINOR CHILD(REN) OR PROPERTY

I, {full legal name} , Respondent, being sworn,
certify that the following information is true:

ANSWER TO PETITION
l. I agree with Petitioner as to the allegations raised in the following numbered paragraphs in the
Petition and, therefore, admit those allegations: {indicate section and paragraph number}
.

2. I disagree with Petitioner as to the allegations raised in the following numbered paragraphs in the
Petition and, therefore, deny those allegations: {indicate section and paragraph number}
.

3. I currently am unable to admit or deny the following paragraphs due to lack of information: {indicate
section and paragraph number}
.

COUNTERPETITION FOR DISSOLUTION OF MARRIAGE WITH NO DEPENDENT OR
MINOR CHILD(REN) OR PROPERTY

1. JURISDICTION/RESIDENCE
_____Husband _____ Wife _____ Both has (have) lived in Florida for at least 6 months before the
filing of this Petition for Dissolution of Marriage.

2. Petitioner _____ is or _____ is not a member of the military service.

Florida Supreme Court Approved Family Law Form 12.903(c)(3), Answer to Petition and
Counterpetition for Dissolution of Marriage with No Dependent or Minor Child(ren) or Property
(03/15)
- 114 -
Respondent _____ is or _____ is not a member of the military service.

3. MARRIAGE HISTORY
Date of marriage: {month, day, year}
Place of marriage: {city, state, country}
Date of separation: {month, day, year} (_____Indicate if approximate)

4. THERE ARE NO MINOR (under 18) OR DEPENDENT CHILD(REN) COMMON TO BOTH PARTIES AND
THE WIFE IS NOT PREGNANT.

5. A completed Notice of Social Security Number, Florida Supreme Court Approved Family Law Form
12.902(j), is filed with this counterpetition.
6. THIS COUNTERPETITION FOR DISSOLUTION OF MARRIAGE SHOULD BE GRANTED BECAUSE:

a. _____The marriage is irretrievably broken.

b. _____One of the parties has been adjudged mentally incapacitated for a period of 3 years before the
filing of this counterpetition. A copy of the Judgment of Incapacity is attached.

7. THERE ARE NO MARITAL ASSETS OR LIABILITIES.
8. RESPONDENT FOREVER GIVES UP HIS/HER RIGHTS TO SPOUSAL SUPPORT (ALIMONY) FROM
PETITIONER.
9. _____ [If Respondent is also the Wife], Wife wants to be known by her former name, which was {full
legal name} .
10. Other relief {specify}:

REQUEST
(This section summarizes what you are asking the Court to include in the final judgment of dissolution

Florida Supreme Court Approved Family Law Form 12.903(c)(3), Answer to Petition and
Counterpetition for Dissolution of Marriage with No Dependent or Minor Child(ren) or Property
(03/15)
- 115 -
of marriage.)
Respondent requests that the Court enter an order dissolving the marriage and:

1. ______restoring Wife’s former name as specified in paragraph 9 of this petition;

2. _____ awarding other relief as specified in paragraph 10 of this petition; and any other terms the
Court deems necessary.

I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand
delivered to the person(s) listed below on {date} .

Petitioner or his/her attorney:
Name:
Address:
City, State, Zip: ______
Fax Number:
Designated E-mail Address(es):______________________________________________

Dated:
Signature of Respondent
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es):____________________
_____________________________________________

STATE OF FLORIDA
COUNTY OF

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

Florida Supreme Court Approved Family Law Form 12.903(c)(3), Answer to Petition and
Counterpetition for Dissolution of Marriage with No Dependent or Minor Child(ren) or Property
(03/15)
- 116 -
[Print, type, or stamp commissioned name of notary or clerk.]
__ Personally known
__ Produced identification
Type of identification produced

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the {choose only one} ( ) Husband ( ) Wife.
This form was completed with the assistance of:
{name of individual} _________________________________________________________________,
{name of business} __________________________________________________________________,
{address} __________________________________________________________________________,
{city} ______________, {state} _____,{zip code}___________,{telephone number} _______________.

Florida Supreme Court Approved Family Law Form 12.903(c)(3), Answer to Petition and
Counterpetition for Dissolution of Marriage with No Dependent or Minor Child(ren) or Property
(03/15)
- 117 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.903(d)
ANSWER TO COUNTERPETITION (03/15)
When should this form be used?

This form should be used by a petitioner to respond to the respondent’s counterpetition. You should
use this form to admit or deny the allegations contained in the counterpetition.

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?

You have 20 days to answer after being served with the other party’s counterpetition. A copy of this
form must be mailed, e-mailed, or hand delivered to the other party.

To proceed with your case, you should refer to the instructions to your petition regarding setting a case
for trial under UNCONTESTED and CONTESTED.

Where can I look for more information?
Before proceeding, you should read General Information for Self-Represented Litigants found at the
beginning of these forms. The words that are in bold underline in these instructions are defined there.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions for Florida Supreme Court Approved Family Law Form 12.903(d), Answer to
Counterpetition (03/15)
- 118 -
After the initial service of process of the petition or supplemental petition by the Sheriff or certified
process server, the Florida Rules of Judicial Administration now require that all documents required or
permitted to be served on the other party must be served by electronic mail (e-mail) except in certain
circumstances. You must strictly comply with the format requirements set forth in the Rules of Judicial
Administration.

Special notes...

Instructions for Florida Supreme Court Approved Family Law Form 12.903(d), Answer to
Counterpetition (03/15)
- 119 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:

_________________________________ ,
Petitioner/Counterrespondent,

and

_________________________________,
Respondent/Counterpetitioner.

ANSWER TO COUNTERPETITION

I, {full legal name} , being sworn, certify that the following
information is true:

1. I agree with Respondent as to the allegations raised in the following numbered paragraphs in
the Counterpetition and, therefore, admit those allegations: {indicate section and paragraph
number}
.

2. I disagree with Respondent as to the allegations raised in the following numbered paragraphs in
the Counterpetition and, therefore, deny those allegations: {indicate section and paragraph
number}
.

3. I am currently unable to admit or deny the following paragraphs due to lack of information:
{indicate section and paragraph number}
________________________ .

I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed
( ) hand-delivered to the person(s) listed below on {date} ____________________________.

Respondent or his/her attorney:
Name:
Address:
City, State, Zip:

Florida Supreme Court Approved Family Law Form 12.903(d), Answer to Counterpetition
(03/15)
- 120 -
Fax Number:
Designated E-mail Address(es):______________________
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
answer and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.

Dated: ________________
_____________________________________________
Signature of Petitioner
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es): ____________________
_____________________________________________

STATE OF FLORIDA
COUNTY OF _______

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

[Print, type, or stamp commissioned name of notary or clerk.]
_ Personally known
_ Produced identification
Type of identification produced

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the Petitioner.
This form was completed with the assistance of:
{name of individual} __________________________________________________________________,
{name of business} ___________________________________________________________________,
{address} __________________________________________________,
{city} ____________,{state} ___,{zip code}____________, {telephone number}________________.

Florida Supreme Court Approved Family Law Form 12.903(d), Answer to Counterpetition
(03/15)
- 121 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY
LAW FORM 12.903(e),
ANSWER TO SUPPLEMENTAL PETITION (03/15)

When should this form be used?

This form should be used when you are responding to a supplemental petition for modification of
Parenting Plan, time-sharing schedule, child support, or alimony. This form is used to admit or deny
all of the allegations in the supplemental petition if you do not plan to file a counterpetition. There
is no form for a counterpetition to a supplemental petition in these Family Law Forms. If you want
to file a counterpetition to a supplemental petition you will need to either seek legal assistance or
create a form yourself. You may construct an answer and counterpetition using the pertinent
sections contained in the Answer to Petition and Counterpetition for Dissolution of Marriage with
Dependent or Minor Child(ren), Florida Supreme Court Approved Family Law Form 12.903(c)(1), or
Answer to Petition and Counterpetition for Dissolution of Marriage with Property but No
Dependent or Minor Child(ren), Florida Supreme Court Approved Family Law Form 12.903(c)(2).

IMPORTANT INFORMATION REGARDING E-FILING

The Florida Rules of Judicial Administration now require that all petitions, pleadings, and documents
be filed electronically except in certain circumstances. Self-represented litigants may file petitions
or other pleadings or documents electronically; however, they are not required to do so. If you
choose to file your pleadings or other documents electronically, you must do so in accordance with
Florida Rule of Judicial Administration 2.525, and you must follow the procedures of the judicial
circuit in which you file. The rules and procedures should be carefully read and followed.

What should I do next?

A copy of this form, along with all of the other forms required with this answer, must be mailed, e-
mailed, or hand delivered to the other party in your case. Regardless of whether you file a
counterpetition, you have 20 days to answer after being served with the other party’s supplemental
petition. After you file your answer, the case will generally proceed in one of the following two
ways:

Instructions for Florida Supreme Court Approved Family Law Form 12.903(e), Answer to
Supplemental Petition (03/15)
- 122 -
UNCONTESTED... If you file an answer that agrees with everything in the other party’s supplemental
petition and you have complied with mandatory disclosure and filed all of the required papers,
either party may call the clerk, family law intake staff, or judicial assistant to set a final hearing. If
you request the hearing, you must notify the other party of the hearing by using a Notice of Hearing
(General), Florida Supreme Court Approved Family Law Form 12.923, or other appropriate notice of
hearing form.

CONTESTED... If you file an answer which disagrees with or denies anything in the supplemental
petition, and you are unable to settle the disputed issues, either party may file a Notice for Trial,
Florida Supreme Court Approved Family Law Form 12.924, after you have complied with mandatory
disclosure and filed all of the required papers. Some circuits may require the completion of
mediation before a final hearing may be set. If you request the hearing, you should contact the
clerk, family law intake staff, or judicial assistant for instructions on how to set your case for trial
(final hearing).

Where can I look for more information?

Before proceeding, you should read “General Information for Self-Represented Litigants” found at
the beginning of these forms. The words that are in “bold underline” in these instructions are
defined there. See chapter 61, Florida Statutes, for more information.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

To serve and receive documents by e-mail, you must designate your e-mail addresses by using the
Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family Law
Form 12.915, and you must provide your e-mail address on each form on which your signature
appears. Please CAREFULLY read the rules and instructions for: Certificate of Service (General),
Florida Supreme Court Approved Family Law Form 12.914; Designation of Current Mailing and E-

Instructions for Florida Supreme Court Approved Family Law Form 12.903(e), Answer to
Supplemental Petition (03/15)
- 123 -
mail Address, Florida Supreme Court Approved Family Law Form 12.915; and Florida Rule of Judicial
Administration 2.516.

Special notes...

With this form, you must also file the following:

 Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida
Supreme Court Approved Family Law Form 12.902(d), if the case involves child(ren).
 Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form
12.902(e), if child support is an issue. (If you do not know the other party=s income, you
may file this worksheet after his or her financial affidavit has been served on you.)
 Settlement Agreement, if you have reached an agreement on any or all of the issues.
Although there is no form for this in these Florida Family Law Forms, you may construct a
settlement agreement using the pertinent sections contained in Marital Settlement
Agreement for Dissolution of Marriage with Dependent or Minor Child(ren), Florida
Supreme Court Approved Family Law Form 12.902(f)(1), or Marital Settlement Agreement
for Dissolution of Marriage with [Property but] No Dependent or Minor Child(ren), Florida
Supreme Court Approved Family Law Form 12.902(f)(2).
 Notice of Social Security Number, Florida Supreme Court Approved Family Law Form
12.902(j), if not previously filed.
 Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or (c).
(This must be filed within 45 days of service of the supplemental petition on you, if not filed
at the time you file your answer.)
 Certificate of Compliance with Mandatory Disclosure, Florida Family Law Rules of
Procedure Form 12.932. (This must be filed within 45 days of service of the supplemental
petition on you, if not filed at the time of you file your answer, unless you and the other
party have agreed not to exchange these documents.)

Parenting and Time-Sharing... If you and the other party are unable to agree on parenting
arrangements and a time-sharing schedule, a judge will decide for you as part of establishing a
Parenting Plan. The judge will decide the parenting arrangements and time-sharing schedule based
on the child(ren)’s best interests. Regardless of whether there is an agreement, the court reserves
jurisdiction to modify issues relating to the minor child(ren).

The judge may request a parenting plan recommendation or appoint a guardian ad litem in your case.
This means that a neutral person will review your situation and report to the judge concerning
parenting issues. The purpose of such intervention is to be sure that the best interests of the
child(ren) is (are) being served. For more information, you may consult section 61.13, Florida Statutes.
A parenting course may be required prior to entry of a final judgment. You should contact the clerk,
family law intake staff, or judicial assistant about requirements for parenting courses or mediation
where you live.

Listed below are some terms with which you should become familiar before completing your
supplemental petition. If you do not fully understand any of the terms below or their implications,

Instructions for Florida Supreme Court Approved Family Law Form 12.903(e), Answer to
Supplemental Petition (03/15)
- 124 -
you should speak with an attorney before going any further.

Shared Parental Responsibility
Sole Parental Responsibility
Supervised Time-Sharing
No contact
Parenting Plan
Parenting Plan Recommendation
Time-Sharing Schedule

Child Support... If this case involves child support issues, the court may order one parent to pay
child support to assist the other parent in meeting the child(ren)’s material needs. Both parents are
required to provide financial support, but one parent may be ordered to pay a portion of his or her
support for the child(ren) to the other parent. Florida has adopted guidelines for determining the
amount of child support to be paid. These guidelines are based on the combined income of both
parents and take into account the financial contributions of both parents. You must file a Family
Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or (c), and the other
parent will be required to do the same. From your financial affidavits, you should be able to
calculate the amount of child support that should be paid using the Child Support Guidelines
Worksheet, Florida Family Law Rules of Procedure Form 12.902(e). Because the child support
guidelines take several factors into consideration, change over time, and vary from state to state,
your child support obligation may be more or less than that of other people in seemingly similar
situations.

Temporary Relief... If you need temporary relief regarding parental responsibility and time-sharing
with child(ren), child support or alimony, you may file a Motion for Temporary Support with
Dependent or Minor Child(ren), Florida Supreme Court Approved Family Law Form 12.947(a) or, if
you need temporary relief regarding alimony and there are no dependent or minor child(ren), you
may file a Motion for Temporary Support with No Dependent or Minor Child(ren), Florida Supreme
Court Approved Family Law Form 12.947(c). For more information, see the instructions for these
forms.

Settlement Agreement... If you and the other party are able to reach an agreement on any or all of
the issues, you should file a Settlement Agreement. Although there is no form for this in these
Florida Family Law Forms, you may construct a settlement agreement using the pertinent sections
contained in Marital Settlement Agreement for Dissolution of Marriage with Dependent or Minor
Child(ren), Florida Supreme Court Approved Family Law Form 12.902(f)(1), or Marital Settlement
Agreement for Dissolution of Marriage with No Dependent or Minor Child(ren), Florida Supreme
Court Approved Family Law Form 12.902(f)(2). Both parties must sign this agreement before a
notary public or deputy clerk. Any issues on which you are unable to agree will be considered
contested and settled by the judge at the final hearing.

Instructions for Florida Supreme Court Approved Family Law Form 12.903(e), Answer to
Supplemental Petition (03/15)
- 125 -
Final Judgment Form... These family law forms contain a Supplemental Final Judgment Modifying
Parental Responsibility, Visitation, or Parenting Plan/Time-Sharing Schedule or Other Relief,
Florida Supreme Court Approved Family Law Form 12.993(a), a Supplemental Final Judgment
Modifying Child Support, Florida Supreme Court Approved Family Law Form 12.993(b), and a
Supplemental Final Judgment Modifying Alimony, Florida Supreme Court Approved Family Law
Form 12.993(c), which the judge may use, as appropriate. You should check with the clerk, family
law intake staff, or judicial assistant to see if you need to bring a final judgment with you to the
hearing. If so, you should type or print the heading, including the circuit, county, case number,
division, and the parties’ names, and leave the rest blank for the judge to complete at your hearing
or trial.

Nonlawyer... Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer
helps you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer,
Florida Family Law Rules of Procedure Form 12.900(a), before he or she helps you. A nonlawyer
helping you fill out these forms also must put his or her name, address, and telephone number on
the bottom of the last page of every form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.903(e), Answer to
Supplemental Petition (03/15)
- 126 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
,
Petitioner,

and

,
Respondent.

ANSWER TO SUPPLEMENTAL PETITION

I, {full legal name} , being sworn, certify that the
following information is true:

1. I agree with Petitioner as to the allegations raised in the following numbered paragraphs in the
Supplemental Petition and, therefore, admit those allegations: {indicate section and paragraph
number}

2. I disagree with Petitioner as to the allegations raised in the following numbered paragraphs in
the Supplemental Petition and, therefore, deny those allegations: {indicate section and
paragraph number}

3. I currently am unable to admit or deny the following paragraphs due to lack of information:
{indicate section and paragraph number}

4. If not previously filed in this case, a completed Family Law Financial Affidavit, Florida Family Law
Rules of Procedure Form 12.902(b) or (c) _____ is filed with this answer, or _____ will be timely
filed.

5. If not previously filed in this case, a completed Notice of Social Security Number, Florida
Supreme Court Approved Family Law Form 12.902(j), is filed with this answer.

6. __{If applicable} This case involves minor child(ren), and a completed Uniform Child Custody
Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida Supreme Court Approved Family
Law Form 12.902(d), is filed with this answer.

7. __{If applicable} This case involves child support, and a completed Child Support Guidelines
Worksheet, Florida Family Law Rules of Procedure Form 12.902(e),_____ is filed or _____ will be
timely filed with the court.
I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand

Florida Supreme Court Approved Family Law Form 12.903(e), Answer to Supplemental Petition
(03/15)
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delivered to the person(s) listed below on {date} .

Petitioner or his/her attorney:
Name:
Address:
City, State, Zip: ______
Fax Number:
Designated E-mail Address(es):__________________
__________________________________________

Dated:
__________________________________
Signature of Respondent
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es):__________________
__________________________________________

STATE OF FLORIDA
COUNTY OF ________________________

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

[Print, type, or stamp commissioned name of notary or clerk.]
__ Personally known
__ Produced identification
Type of identification produced _____________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the Respondent.
This form was completed with the assistance of:
{name of individual} _____________________________________________________________ ,
{name of business} _______________________________________________________________ ,

Florida Supreme Court Approved Family Law Form 12.903(e), Answer to Supplemental Petition
(03/15)
- 128 -
{address} _______________________________________ ,
{city} ____,{state} __, {zip code}______________, {telephone number} .

Florida Supreme Court Approved Family Law Form 12.903(e), Answer to Supplemental Petition
(03/15)
- 129 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.904(a),
PETITION FOR SUPPORT UNCONNECTED WITH DISSOLUTION OF
MARRIAGE WITH DEPENDENT OR MINOR CHILD(REN)
(03/15)

When should this form be used?

This form may be used to ask the court to enter a support order if your spouse has the ability to
contribute to you and your minor child(ren), but has failed to do so. You can only use this form if a
dissolution of marriage has not been filed and based upon the time-sharing schedule, you are entitled
to support. If a petition for dissolution of marriage has been filed, you should file a Motion for
Temporary Support and Time-Sharing with Dependent or Minor Child(ren), Florida Supreme Court
Approved Family Law Form 12.947(a), instead of using this petition. Also, if you are requesting that an
order be entered for you to pay support to your spouse, you should not file this form.

This petition cannot address the issues of property, debts, or parental responsibility and time-sharing
with child(ren). It only deals with alimony and child support.

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?

For your case to proceed, you must properly notify your spouse of the petition. Because this petition
concerns child support and alimony, you should use personal service. If your spouse is in the military
service of the United States, additional steps for service may be required. See, for example,
Memorandum for Certificate of Military Service, Florida Supreme Court Approved Family Law Form
12.912(a) and Affidavit of Military Service, Florida Supreme Court Approved Family Law Form
12.912(b). Service on a spouse who is in the military can be complicated; therefore, you may wish to
consult an attorney regarding this issue.

Instructions for Florida Supreme Court Approved Family Law Form 12.904(a), Petition for
Support Unconnected with Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
- 130 -
Your spouse has 20 days to answer after being served with your petition. Your case will then generally
proceed in one of the following three ways:

DEFAULT. If after 20 days, no answer has been filed, you may file a Motion for Default, Florida Supreme
Court Approved Family Law Form 12.922(a), with the clerk of court. Then, if you have filed all of the
required papers, you may call the clerk, family law intake staff, or judicial assistant to set a final
hearing. You must notify your spouse of the hearing by using a Notice of Hearing (General), Florida
Supreme Court Approved Family Law Form 12.923, or other appropriate notice of hearing form.

CONTESTED. If your spouse files an answer or an answer and counterpetition, which disagrees with or
denies anything in your petition, and you are unable to settle the disputed issues, you should file a
Notice for Trial, Florida Supreme Court Approved Family Law Form 12.924, after you have complied with
mandatory disclosure and filed all of the required papers. Some circuits may require the completion of
mediation before a final hearing may be set. Then you should contact the clerk, family law intake staff,
or judicial assistant for instructions on how to set your case for trial (final hearing). If your spouse files
an answer and counterpetition, you should answer the counterpetition within 20 days using an Answer
to Counterpetition, Florida Supreme Court Approved Family Law Form 12.903(d).

Where can I look for more information?

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

To serve and receive documents by e-mail, you must designate your e-mail addresses by using the
Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family Law Form
Instructions for Florida Supreme Court Approved Family Law Form 12.904(a), Petition for
Support Unconnected with Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
- 131 -
12.915, and you must provide your e-mail address on each form on which your signature appears.
Please CAREFULLY read the rules and instructions for: Certificate of Service (General), Florida Supreme
Court Approved Family Law Form 12.914; Designation of Current Mailing and E-mail Address, Florida
Supreme Court Approved Family Law Form 12.915; and Florida Rule of Judicial Administration 2.516.

Special notes...

With this form you must also file the following:

 Notice of Social Security Number, Florida Supreme Court Approved Family Law Form 12.902(j).
 Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida Supreme
Court Approved Family Law Form 12.902(d), if the case involves minor or dependent child(ren).
 Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or (c).
 Certificate of Compliance with Mandatory Disclosure, Florida Family Law Rules of Procedure
Form 12.932. (This must be filed within 45 days of service of the petition on the respondent, if
not filed at the time of the petition, unless you and the other party have agreed not to exchange
these documents.)
 Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e), if
you are asking that child support be ordered in the final judgment. (If you do not know the
other party’s income, you may file this worksheet after his or her financial affidavit has been
served on you.)
Alimony. Alimony may be awarded to a spouse if the judge finds that he or she has an actual need for it
and that the other spouse has the ability to pay. If you want alimony, you must request it in writing in
the original petition. If you do not request alimony in writing before the final hearing, it is waived (you
may not request it later). You may request permanent alimony, bridge-the-gap alimony, durational
alimony, lump sum alimony, or rehabilitative alimony.

Child Support. The court may order one parent to pay child support to assist the other parent in
meeting the child(ren)’s material needs. Both parents are required to provide financial support, but
one parent may be ordered to pay a portion of his or her support for the child(ren) to the other parent.
Florida has adopted guidelines for determining the amount of child support to be paid. These guidelines
are based on the combined income of both parents and take into account the financial contributions of
both parents and the number of overnights the child(ren) spend with each parent. You must file a
Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or (c), and your
spouse will be required to do the same. From your financial affidavits, you should be able to calculate
the amount of child support that should be paid using the Child Support Guidelines Worksheet, Florida
Family Law Rules of Procedure Form 12.902(e). Because the child support guidelines take several
factors into consideration, change over time, and vary from state to state, your child support obligation
may be more or less than that of other people in seemingly similar situations.

Instructions for Florida Supreme Court Approved Family Law Form 12.904(a), Petition for
Support Unconnected with Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
- 132 -
Temporary Relief. If you need temporary relief regarding child support or temporary alimony, you may
file a Motion for Temporary Support and Time-Sharing with Dependent or Minor Child(ren), Florida
Supreme Court Approved Family Law Form 12.947(a). For more information, see the instructions for
that form.

Final Judgment Forms. These family law forms contain a Final Judgment of Support Unconnected with
Dissolution of Marriage with Dependent or Minor Child(ren), Florida Supreme Court Approved Family
Law Form 12.994(a), which the judge may use if your case is contested. You should check with the clerk,
family law intake staff, or judicial assistant to see if you need to bring a final judgment with you to the
hearing. If so, you should type or print the heading, including the circuit, county, case number, division,
and the parties’ names, and leave the rest blank for the judge to complete at your hearing or trial.

Nonlawyer. Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps
you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida
Family Law Rules of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill
out these forms also must put his or her name, address, and telephone number on the bottom of the
last page of every form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.904(a), Petition for
Support Unconnected with Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
- 133 -
IN THE CIRCUIT COURT OF THE _____________________ JUDICIAL CIRCUIT,
IN AND FOR ______________________________ COUNTY, FLORIDA

In re: the Marriage of: Case No: ________________________
Division: ________________________

_________________________________,
Husband,
and

_________________________________,
Wife.

PETITION FOR SUPPORT UNCONNECTED WITH DISSOLUTION OF
MARRIAGE WITH DEPENDENT OR MINOR CHILD(REN)
I, {full legal name} , the
( ) Husband ( ) Wife, the Petitioner, being sworn, certify that the following statements are true:

1. JURISDICTION
_____ Husband _____ Wife ____ Both live in Florida at the filing of this Petition for Support
Unconnected with Dissolution of Marriage, which is filed pursuant to section 61.09, Florida Statutes.

2. Husband _____ is or _____ is not a member of the military service.
Wife _____ is or _____ is not a member of the military service.

3. MARRIAGE HISTORY
Date of marriage: {month, day, year} ______________________
Date of separation: {month, day, year} ________________ (____Indicate if approximate)

4. MINOR CHILD(REN)
[Indicate all that apply]
a. ____The wife is pregnant. The baby is due on: {date} _____.

b. ____The minor (under 18) child(ren) common to both parties are:

Name Birth date
____
______
_____
______
______
______

c. The minor child(ren) born or conceived during the marriage who are not common to both
parties are:

Florida Supreme Court Approved Family Law Form 12.904(a), Petition for Support Unconnected
with Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
- 134 -
Name Birth date
_____________________________________________________________________________________
_____________________________________________________________________________________
________________________________________________________________________

The birth father(s) of the above minor child(ren) is (are) {name and address}
_____________________________________________________________________

d. ____The child(ren) common to both parties who are 18 or older but who are dependent
upon the parties due to a mental or physical incapacity are:
Name Birth date
____________
_____________

5. A completed Notice of Social Security Number, Florida Supreme Court Approved Family Law
Form 12.902(j), is filed with this petition.

6. A completed Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form
12.902(b) or (c) _____ is filed with this petition or _____ will be timely filed.

7. A completed Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form
12.902(e) _____ is filed with this petition, or _____ will be timely filed.

8. A completed Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida
Supreme Court Approved Family Law Form 12.902(d), is filed with this petition.

SECTION I. SPOUSAL SUPPORT (ALIMONY)

1. ____Husband ____ Wife does not request spousal support (alimony) from the other spouse at
this time.

2. ____ Husband ____Wife has the ability to contribute to the maintenance of the other spouse
and has failed to do so.____ Husband ____Wife requests that the Court order the other spouse
to pay the following spousal support (alimony) and claims that he or she has a need for the
support that he or she is requesting. Spousal support (alimony) is requested in the amount of
$______________ every _____ week _____ other week _____ month, beginning {date}
________________________, and continuing until {date or event} ____________________ .

Explain why the Court should order ____ Husband ____ Wife to pay and any specific request(s) for type
of alimony (temporary, permanent, rehabilitative, bridge-the-gap, durational, and/or lump
sum):_____________________________________________________________________

Florida Supreme Court Approved Family Law Form 12.904(a), Petition for Support Unconnected
with Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
- 135 -
.

3. ____Other provisions relating to alimony including any tax treatment and consequences:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

4. _____Husband ____ Wife requests life insurance on the other spouse’s life, provided by that
spouse, to secure such support.

SECTION II. CHILD SUPPORT
1. ____ Husband ____Wife has the ability to contribute to the maintenance of his or her minor
child(ren) and has failed to do so. Based upon the time-sharing schedule, the ____Husband
_____Wife is entitled to child support.

[Indicate all that apply]
2. ____Husband ____Wife requests that the Court award child support as determined by Florida’s
child support guidelines, section 61.30, Florida Statutes.

3. ____ Husband ____ Wife requests that the Court award child support to be paid beyond the age
of 18 years by ____Husband ____Wife because:

a.____the following child(ren), {name(s)} ,
is (are) dependent because of a mental or physical incapacity which began prior to the age of 18
{explain}:
_______________________________________________________________________
_______________________________________________________________________

b.____the following child(ren), {name(s)} ,
is (are) dependent in fact, is (are) in high school and is (are) between the ages of 18 and 19; said
child(ren) is (are) performing in good faith with a reasonable expectation of graduation before the age
of 19.

4. ____ Husband ____ Wife requests that medical/dental insurance for the minor child(ren) be
provided by: [Choose only one]
a. ____ Husband.

b. ____ Wife.

5. ____ Husband ____ Wife requests that uninsured medical/dental expenses for the child(ren) be
paid: [Choose only one]

a. ____ by Husband.

b. ____ by Wife.

c. ____ by Husband and Wife each paying one-half.

d. __according to the percentages in the Child Support Guidelines Worksheet, Florida
Family Law Rules of Procedure Form 12.902(e).
Florida Supreme Court Approved Family Law Form 12.904(a), Petition for Support Unconnected
with Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
- 136 -
e. _ Other {explain}: ___________________________________________________.

6. _____Husband ____ Wife requests that life insurance to secure child support be provided by:

a._____Husband

b._____Wife

c._____Both

SECTION III. OTHER RELIEF

SECTION IV. REQUEST
(This section summarizes what you are asking the Court to include in the order for support.)
_____ Husband ____ Wife requests that the Court enter an order establishing support and:
[Indicate all that apply]
a. ____ awarding spousal support (alimony) as requested in Section I of this petition;

b. ____ establishing child support for the minor child(ren) common to both parties, as requested in
Section II of this petition;

c. ____ awarding other relief as requested in Section III of this petition; and any other items the
Court deems necessary.

Dated:

Signature of ( ) Husband ( ) Wife
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es): __________________
__________________________________________

Florida Supreme Court Approved Family Law Form 12.904(a), Petition for Support Unconnected
with Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
- 137 -
STATE OF FLORIDA
COUNTY OF

Sworn to or affirmed and signed before me on by .

_____________________________________________
NOTARY PUBLIC or DEPUTY CLERK

[Print, type, or stamp commissioned name of notary or deputy clerk.]
_ Personally known
__ Produced identification
Type of identification produced ___________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Husband ( ) Wife
This form was completed with the assistance of:
{name of individual}_______________________________________________________________ ,
{name of business} _________________________________________________________________ ,
{address} ________________________________________________________________________ ,
{city} ____________, {state} ____, {zip code}____________, {telephone number} _______________ .

Florida Supreme Court Approved Family Law Form 12.904(a), Petition for Support Unconnected
with Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
- 138 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.904(b),
PETITION FOR SUPPORT UNCONNECTED WITH DISSOLUTION OF
MARRIAGE WITH NO DEPENDENT OR MINOR CHILD(REN)(03/15)

When should this form be used?

This form may be used if a dissolution of marriage has not been filed, and you are requesting alimony.
If a petition for dissolution has been filed, you should file a Motion for Temporary Support with No
Dependent or Minor Child(ren), Florida Supreme Court Approved Family Law Form 12.947(c), instead of
using this petition. Also, if you are requesting that an order be entered for you to pay support to your
spouse, you should not file this form.

This petition does not address the issues of property or debts. It only deals with alimony.

This form should be typed or printed in black ink. After completing this form, you should sign the form
before a notary public or deputy clerk. You should file the original with the clerk of the circuit court in
the county where you live and keep a copy for your records. Because you are filing the petition in this
proceeding, you are also referred to as the petitioner and your spouse as the respondent.

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?

For your case to proceed, you must properly notify your spouse of the petition. Because this petition
concerns alimony, you should use personal service. If your spouse is in the military service of the United
States, additional steps for service may be required. See, for example, Memorandum for Certificate of
Military Service, Florida Supreme Court Approved Family Law Form 12.912(a) and Affidavit of Military
Service, Florida Supreme Court Approved Family Law Form 12.912(b). Service on a spouse who is in the
military can be complicated; therefore, you may wish to consult an attorney regarding this issue.

Your spouse has 20 days to answer after being served with your petition. Your case will then generally
proceed in one of the following three ways:

Instructions for Florida Supreme Court Approved Family Law Form 12.904(b), Petition for
Support Unconnected with Dissolution of Marriage with No Dependent or Minor Child(ren)
(03/15)
- 139 -
DEFAULT... If after 20 days, no answer has been filed, you may file a Motion for Default, Florida
Supreme Court Approved Family Law Form 12.922(a), with the clerk of court. Then, if you have filed all
of the required papers, you may call the clerk, family law intake staff, or judicial assistant to set a final
hearing. You must notify your spouse of the hearing by using a Notice of Hearing (General), Florida
Supreme Court Approved Family Law Form 12.923, or other appropriate notice of hearing form.

CONTESTED... If your spouse files an answer or an answer and counterpetition, which disagrees with or
denies anything in your petition, and you are unable to settle the disputed issues, you should file a
Notice for Trial, Florida Supreme Court Approved Family Law Form 12.924, after you have complied with
mandatory disclosure and filed all of the required papers. Some circuits may require the completion of
mediation before a final hearing may be set. Then you should contact the clerk, family law intake staff,
or judicial assistant for instructions on how to set your case for trial (final hearing). If your spouse files
an answer and counterpetition, you should answer the counterpetition within 20 days using an Answer
to Counterpetition, Florida Supreme Court Approved Family Law Form 12.903(d).

Where can I look for more information?

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

To serve and receive documents by e-mail, you must designate your e-mail addresses by using the
Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family Law Form
12.915, and you must provide your e-mail address on each form on which your signature appears.
Please CAREFULLY read the rules and instructions for: Certificate of Service (General), Florida Supreme

Instructions for Florida Supreme Court Approved Family Law Form 12.904(b), Petition for
Support Unconnected with Dissolution of Marriage with No Dependent or Minor Child(ren)
(03/15)
- 140 -
Court Approved Family Law Form 12.914; Designation of Current Mailing and E-mail Address, Florida
Supreme Court Approved Family Law Form 12.915; and Florida Rule of Judicial Administration 2.516.

Special notes...

With this form you must also file the following:

 Notice of Social Security Number, Florida Supreme Court Approved Family Law Form 12.902(j).
 Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or (c). (This
must be filed within 45 days of service of the petition on the respondent, if not filed at the time of
the petition.)
 Certificate of Compliance with Mandatory Disclosure, Florida Family Law Rules of Procedure Form
12.932. (This must be filed within 45 days of service of the petition on the respondent, if not filed at
the time of the petition, unless you and the other party have agreed not to exchange these
documents.)

Alimony... Alimony may be awarded to a spouse if the judge finds that he or she has an actual need for
it and that the other spouse has the ability to pay. If you want alimony, you must request it in writing
in the original petition. If you do not request alimony in writing before the final hearing, it is waived
(you may not request it later). You may request permanent alimony, bridge-the-gap alimony,
durational alimony, lump sum alimony, or rehabilitative alimony.

Temporary Relief... If you need temporary relief regarding alimony, you may file a Motion for
Temporary Support with No Dependent or Minor Child(ren), Florida Supreme Court Approved Family
Law Form 12.947(c). For more information, see the instructions for that form.

Final Judgment Forms... These family law forms contain a Final Judgment of Support Unconnected
with Dissolution of Marriage with No Dependent or Minor Child(ren), Florida Supreme Court Approved
Family Law Form 12.994(b), which the judge may use if your case is contested. You should check with
the clerk, family law intake staff, or judicial assistant to see if you need to bring a final judgment with
you to the hearing. If so, you should type or print the heading, including the circuit, county, case
number, division, and the parties’ names, and leave the rest blank for the judge to complete at your
hearing or trial.

Nonlawyer... Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps
you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida
Family Law Rules of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill
out these forms also must put his or her name, address, and telephone number on the bottom of the
last page of every form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.904(b), Petition for
Support Unconnected with Dissolution of Marriage with No Dependent or Minor Child(ren)
(03/15)
- 141 -
IN THE CIRCUIT COURT OF THE _____________________ JUDICIAL CIRCUIT,
IN AND FOR ______________________________ COUNTY, FLORIDA

In re: the Marriage of: Case No: ________________________
Division: ________________________

_________________________________,
Husband,
and

_________________________________,
Wife.

PETITION FOR SUPPORT UNCONNECTED WITH DISSOLUTION OF
MARRIAGE WITH NO DEPENDENT OR MINOR CHILD(REN)
I, {full legal name} ______________________________________________________, the
[Choose only one] _____ Husband _____ Wife, being sworn, certify that the following statements are
true:

1. JURISDICTION
_____ Husband _____ Wife _____ Both live in Florida at the filing of this Petition for Support
Unconnected with Dissolution of Marriage, which is filed pursuant to section 61.09, Florida Statutes.

2. Husband _____ is or _____ is not a member of the military service.
Wife _____ is or _____ is not a member of the military service.

3. MARRIAGE HISTORY
Date of marriage: {month, day, year} ______________________
Date of separation: {month, day, year} _____________________ (____Indicate if approximate)

4. A completed Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or
(c),_____ is filed with this petition or _____ will be timely filed.

5. A completed Notice of Social Security Number, Florida Supreme Court Approved Family Law Form
12.902(j), _____is filed with this petition or _____ will be timely filed.

SECTION I. SPOUSAL SUPPORT (ALIMONY)

1. ____ Husband ____Wife has the ability to contribute to the maintenance of the other spouse and
has failed to do so. _____Husband ____Wife requests that the Court order the other spouse to pay
the following spousal support (alimony) and claims that he or she has a need for the support that he
or she is requesting and that the other spouse has the ability to pay. Spousal support (alimony) is
requested in the amount of $__________every _____ week _____ other week _____ month,
beginning {date} ______________, and continuing until {date or event}_______________________
________________________________________________________________________________.

Florida Supreme Court Approved Family Law Form 12.904(b), Petition for Support Unconnected
with Dissolution of Marriage with No Dependent or Minor Child(ren) (03/15)
- 142 -
Explain why the Court should order ____ Husband ____Wife to pay and any specific request(s) for type
of alimony (temporary, permanent, bridge-the-gap, durational, rehabilitative, and/or lump sum):
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________.

2. _____ Other provisions relating to alimony including any tax treatment and consequences:
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________.

3. ____ Husband ____ Wife requests life insurance on the other spouse’s life, provided by that
spouse, to secure such support.

SECTION II. OTHER RELIEF
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

SECTION III. REQUEST (This section summarizes what you are asking the Court to include in the order
for support.)
____ Husband ____ Wife requests that the Court enter an order establishing support and:
[Indicate all that apply]
a. ____ awarding spousal support (alimony) pursuant to Section I of this petition;

b. ____ awarding other relief as specified in Section II of this petition; and any other terms the Court
deems necessary.

Florida Supreme Court Approved Family Law Form 12.904(b), Petition for Support Unconnected
with Dissolution of Marriage with No Dependent or Minor Child(ren) (03/15)
- 143 -
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
petition and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.

Dated: ______________________ _____________________________________________
Signature of _____ Husband _____ Wife
Printed Name: _________________________________
Address: ______________________________________
City, State, Zip: _________________________________
Telephone Number: _____________________________
Fax Number: __________________________________
Designated E-mail Addresses):_____________________
_____________________________________________

STATE OF FLORIDA
COUNTY OF ____________________

Sworn to or affirmed and signed before me on ____________ by _______________________________.

_____________________________________________
NOTARY PUBLIC or DEPUTY CLERK

_____________________________________________
[Print, type, or stamp commissioned name of notary or deputy clerk.]
____ Personally known
____ Produced identification
____ Type of identification produced ________________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Husband ( ) Wife
This form was completed with the assistance of:
{name of individual} ______________________________________________________________ ,
{name of business} ________________________________________________________________ ,
{address} _________________________________________________________________________ ,
{city} __________________,{state} _____, {zip code}__________, {telephone number} _____________ .

Florida Supreme Court Approved Family Law Form 12.904(b), Petition for Support Unconnected
with Dissolution of Marriage with No Dependent or Minor Child(ren) (03/15)
- 144 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY
LAW FORM 12.905(a),
SUPPLEMENTAL PETITION TO MODIFY PARENTAL RESPONSIBILITY,
VISITATION OR PARENTING PLAN/ TIME–SHARING SCHEDULE AND
OTHER RELIEF (03/15)

When should this form be used?

This form should be used when you are asking the court to change the current parental
responsibility, visitation, and/or Parenting Plan/time-sharing schedule. A determination of parental
responsibility, a Parenting Plan and a time-sharing schedule may not be modified without a showing
of a substantial, material, and unanticipated change in circumstances and a determination that the
modification is in the best interests of the child(ren).

This form should be typed or printed in black ink. After completing this form, you should sign the
form before a notary public or deputy clerk. You should file this form in the county where the
original order or judgment was entered. If the order or judgment was entered in another state, or if
the child(ren) live(s) in another state, you should speak with an attorney about where to file this
form. You should file the original with the clerk of the circuit court and keep a copy for your
records.

IMPORTANT INFORMATION REGARDING E-FILING

The Florida Rules of Judicial Administration now require that all petitions, pleadings, and documents
be filed electronically except in certain circumstances. Self-represented litigants may file petitions
or other pleadings or documents electronically; however, they are not required to do so. If you
choose to file your pleadings or other documents electronically, you must do so in accordance with
Florida Rule of Judicial Administration 2.525, and you must follow the procedures of the judicial
circuit in which you file. The rules and procedures should be carefully read and followed.

What should I do next?

For your case to proceed, you must properly notify the other party in your case of the supplemental
petition. If you know where he or she lives, you should use personal service. If you absolutely do

Instructions for Florida Supreme Court Approved Family Law Form 12.905(a), Supplemental
Petition to Modify Parental Responsibility, Visitation, or Parenting Plan/Time-Sharing
Schedule and Other Relief (03/15)
- 145 -
not know where he or she lives, you may use constructive service. You may also be able to use
constructive service if the other party resides in another state or country. However, if constructive
service is used, other than granting a dissolution of marriage, the court may only grant limited relief.
For more information on constructive service, see Notice of Action for Family Cases with Minor
Child(ren), Florida Supreme Court Approved Family Law Form 12.913(a),(2) and Affidavit of Diligent
Search and Inquiry, Florida Family Law Rules of Procedure Form 12.913(b). If the other party is in
the military service of the United States, additional steps for service may be required. See, for
example, Memorandum for Certificate of Military Service, Florida Supreme Court Approved Family
Law Form 12.912(a). In sum, the law regarding constructive service and service on an individual in
the military service is very complex and you may wish to consult an attorney regarding these issues.

If personal service is used, the other party has 20 days to answer after being served with your
supplemental petition. Your case will then generally proceed in one of the following three ways:

DEFAULT... If after 20 days, no answer has been filed, you may file a Motion for Default, Florida
Supreme Court Approved Family Law Form 12.922(a), with the clerk of court. Then, if you have filed
all of the required papers, you may call the clerk, family law intake staff, or judicial assistant to set
a final hearing. You must notify the other party of the hearing by using a Notice of Hearing
(General), Florida Supreme Court Approved Family Law Form 12.923, or other appropriate notice of
hearing form.

UNCONTESTED... If the respondent files an answer that agrees with everything in your
supplemental petition or an answer and waiver, and you have complied with mandatory disclosure
and filed all of the required papers, you may call the clerk, family law intake staff, or judicial
assistant to set a final hearing. You must notify the other party of the hearing by using a Notice of
Hearing (General), Florida Supreme Court Approved Family Law Form 12.923, or other appropriate
notice of hearing form.

CONTESTED... If the respondent files an answer or an answer and counterpetition, which disagrees
with or denies anything in your supplemental petition, and you are unable to settle the disputed
issues, you should file a Notice for Trial, Florida Supreme Court Approved Family Law Form 12.924,
after you have complied with mandatory disclosure and filed all of the required papers. Some
circuits may require the completion of mediation before a final hearing may be set. Then you should
contact the clerk, family law intake staff, or judicial assistant for instructions on how to set your case
for trial (final hearing). If the respondent files an answer and counterpetition, you should answer
the counterpetition within 20 days using an Answer to Counterpetition, Florida Supreme Court
Approved Family Law Form 12.903(d).

Before proceeding, you should read “General Information for Self-Represented Litigants” found at
the beginning of these forms. The words that are in “bold underline” in these instructions are
defined there. For further information, see chapter 61, Florida Statutes.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

To serve and receive documents by e-mail, you must designate your e-mail addresses by using the
Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family Law
Form 12.915, and you must provide your e-mail address on each form on which your signature
appears. Please CAREFULLY read the rules and instructions for: Certificate of Service (General),
Florida Supreme Court Approved Family Law Form 12.914; Designation of Current Mailing and E-
mail Address, Florida Supreme Court Approved Family Law Form 12.915; and Florida Rule of Judicial
Administration 2.516.

Special notes...

If you do not have the money to pay the filing fee, you may obtain an Application for Determination
of Civil Indigent Status from the clerk, fill it out, and the clerk will determine whether you are eligible
to have filing fees deferred.

With this form, you must also file the following:

Instructions for Florida Supreme Court Approved Family Law Form 12.905(a), Supplemental
Petition to Modify Parental Responsibility, Visitation, or Parenting Plan/Time-Sharing
Schedule and Other Relief (03/15)
- 147 -
if you are seeking to modify child support. (If you do not know the other party’s income,
you may file this worksheet after his or her financial affidavit has been served on you.)
 Parenting Plan, Florida Supreme Court Approved Family Law Form, 12.995(a) or 12.995(b).
If the parties have reached an agreement, the Parenting Plan should be signed by both
parties. If you have not reached an agreement, a proposed Parenting Plan may be filed.
Notice of Social Security Number, Florida Supreme Court Approved Family Law Form
12.902(j), if not previously filed.
 Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or (c).
Certificate of Compliance with Mandatory Disclosure, Florida Family Law Rules of
Procedure Form 12.932 if you are seeking to modify child support. (This must be filed within
45 days of service of the supplemental petition on the respondent, if not filed at the time of
the supplemental petition, unless you and the other party have agreed not to exchange
these documents.)

Parenting Plan and Time-Sharing... If you and the respondent are unable to agree on parenting
arrangements and a time-sharing schedule, a judge will decide for you as part of establishing a
Parenting Plan. The judge will decide the parenting arrangements and time-sharing schedule based
on the child(ren)’s best interests. Regardless of whether there is an agreement, the court reserves
jurisdiction to modify issues relating to the minor child(ren).

A parenting course may be required prior to entry of a final judgment. You should contact the clerk,
family law intake staff, or judicial assistant about requirements for parenting courses or mediation
where you live.

Listed below are some terms with which you should become familiar before completing your
supplemental petition. If you do not fully understand any of the terms below or their implications,
you should speak with an attorney before going any further.

 Shared Parental Responsibility
 Sole Parental Responsibility
 Supervised Time-Sharing
 No contact
 Parenting Plan
 Parenting Plan Recommendation
 Time-Sharing Schedule

Instructions for Florida Supreme Court Approved Family Law Form 12.905(a), Supplemental
Petition to Modify Parental Responsibility, Visitation, or Parenting Plan/Time-Sharing
Schedule and Other Relief (03/15)
- 148 -
Child Support… The court may order one parent to pay child support to assist the other parent in
meeting the child(ren)’s material needs. Both parents are required to provide financial support,
but one parent may be ordered to pay a portion of his or her support for the child(ren) to the other
parent. Florida has adopted guidelines for determining the amount of child support to be paid.
These guidelines are based on the combined income of both parents and take into account the
financial contributions of both parents and the number of overnights the child(ren) spend with each
parent. You must file a Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form
12.902(b) or (c), and the other parent will be required to do the same. From your financial
affidavits, you should be able to calculate the amount of child support that should be paid using the
Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e).
Because the child support guidelines take several factors into consideration, change over time, and
vary from state to state, your child support obligation may be more or less than that of other people
in seemingly similar situations.

Temporary Relief… If you need temporary relief regarding parental responsibility and time-sharing
with child(ren), or temporary child support, you may file a Motion for Temporary Support and
Time-Sharing with Dependent or Minor Child(ren), Florida Supreme Court Approved Family Law
Form 12.947(a). For more information, see the instructions for that form.

Settlement Agreement… If you and the respondent are able to reach an agreement on any or all of
the issues, you should file a Settlement Agreement. Although there is no form for this in these
Florida Family Law Forms, you may construct a settlement agreement using the pertinent sections
contained in Marital Settlement Agreement for Dissolution of Marriage with Dependent or Minor
Child(ren), Florida Supreme Court Approved Family Law Form 12.902(f)(1). Both parties must sign
this agreement before a notary public. Any issues on which you are unable to agree will be
considered contested and settled by the judge at the final hearing.

Final Judgment Form… These family law forms contain a Supplemental Final Judgment Modifying
Parental Responsibility, Visitation, or Parenting Plan/Time-Sharing Schedule And Other Relief,
Florida Supreme Court Approved Family Law Form 12.993(a), which the judge may use. You should
check with the clerk, family law intake staff, or judicial assistant to see if you need to bring it with
you to the hearing. If so, you should type or print the heading, including the circuit, county, case
number, division, and the parties’ names, and leave the rest blank for the judge to complete at your
hearing or trial.

Nonlawyer… Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer
helps you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer,
Florida Family Law Rules of Procedure Form 12.900(a), before he or she helps you. A nonlawyer
helping you fill out these forms also must put his or her name, address, and telephone number on
the bottom of the last page of every form he or she helps you complete.

Case No.:
Division:
,
Petitioner,

and

,
Respondent.

SUPPLEMENTAL PETITION TO MODIFY PARENTAL RESPONSIBILITY,
VISITATION, OR PARENTING PLAN/TIME-SHARING SCHEDULE AND
OTHER RELIEF

I, {full legal name}
_________________________________, being sworn, certify that the following information is
true:

1. The parties to this action were granted a final judgment of _____ dissolution of marriage _____
paternity on {date} ___________________. A copy of the final judgment and any modification(s) is
attached.

2. Paragraph(s) _____ of the _____ final judgment or _____ most recent modification
thereof describes the present parental responsibility, visitation, or Parenting Plan/Time-Sharing
schedule.

3. Since the final judgment or last modification thereof, there has been a substantial, material and
unanticipated change in circumstances, requiring a modification of the parental responsibility,
visitation, or Parenting Plan/Time-Sharing schedule. Those changes are as follows: {explain}

4. I ask the Court to modify the parental responsibility, visitation, Parenting Plan or Time-Sharing
schedule as follows: {explain}

5. Petitioner _____ requests _____ does not request that child support be modified, consistent with
the modification of the Parenting Plan/Time-Sharing schedule.

6. If necessary, a Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form
12.902(e), _____is, or _____ will be filed.

7. A completed Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or
(c), is _____, or _____ will be, filed.

8. A completed Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida
Supreme Court Approved Family Law Form 12.902(d), is filed with this petition.

9. If not previously filed in this case, a completed Notice of Social Security Number, Florida Supreme
Court Approved Family Law Form 12.902(j), is filed with this petition.

10. Other: ___________________________________________________________________________
_________________________________________________________________________________

_____________________________________________________________________________________
______________________________________________________________________________.

Florida Supreme Court Approved Family Law Form 12.905(a), Supplemental Petition to Modify
Parental Responsibility, Visitation, or Parenting Plan/Time-Sharing Schedule and Other Relief
(03/15)
- 151 -
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
petition and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.

Dated: __________________________________________________
Signature of Petitioner

Printed Name: ______________________________________
Address: ___________________________________________
City, State, Zip: ______________________________________
Telephone Number: __________________________________
Fax Number: ________________________________________
Designated E-mail Address(es):__________________________

STATE OF FLORIDA
COUNTY OF

Sworn to or affirmed and signed before me on by

___________________________________________
NOTARY PUBLIC or DEPUTY CLERK

[Print, type, or stamp commissioned name of notary
or deputy clerk.]

_____ Personally known
_____ Produced identification
Type of identification produced _____________________________

Florida Supreme Court Approved Family Law Form 12.905(a), Supplemental Petition to Modify
Parental Responsibility, Visitation, or Parenting Plan/Time-Sharing Schedule and Other Relief
(03/15)
- 152 -
{name of business} _________________________________________________________________ ,
{address} ,
{city}_________________,{state} ______,{zip code}____________, {telephone number} ____ ______.

Florida Supreme Court Approved Family Law Form 12.905(a), Supplemental Petition to Modify
Parental Responsibility, Visitation, or Parenting Plan/Time-Sharing Schedule and Other Relief
(03/15)
- 153 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.905(b)
SUPPLEMENTAL PETITION FOR MODIFICATION OF CHILD SUPPORT
(03/15)

When should this form be used?

This form should be used when you are asking the court to change a current court-ordered child support
obligation. The court can change a child support order or judgment if the judge finds that there has
been a substantial change in the circumstances of the parties and the change is in the child(ren)’s best
interests.

This form should be typed or printed in black ink. After completing this form, you should sign the form
before a notary public or deputy clerk. You should file this form in the county where the original order
was entered. If the order was entered in another state, or if the child(ren) live(s) in another state, you
should speak with an attorney about where to file this form. You should file the original with the clerk
of the circuit court and keep a copy for your records.

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?

For your case to proceed, you must properly notify the other party in your case of the supplemental
petition. If you know where he or she lives, you should use personal service. If you absolutely do not
know where he or she lives, you may use constructive service. You may also be able to use constructive
service if the other party resides in another state or country. However, if constructive service is used,
other than granting a divorce, the court may only grant limited relief. For more information on
constructive service, see Notice of Action for Family Cases with Minor Child(ren), Florida Supreme
Court Approved Family Law Form 12.913(a)(2), and Affidavit of Diligent Search and Inquiry, Florida
Family Law Rules of Procedure Form 12.913(b). If the other party is in the military service of the United
States, additional steps for service may be required. See, for example, Memorandum for Certificate of
Military Service, Florida Supreme Court Approved Family Law Form 12.912(a). In sum, the law regarding
constructive service and service on an individual in the military service is very complex and you may
wish to consult an attorney regarding these issues.

If personal service is used, the other party has 20 days to answer after being served with your
supplemental petition. Your case will then generally proceed in one of the following three ways:

Instructions for Florida Supreme Court Approved Family Law Form 12.905(b), Supplemental
Petition for Modification of Child Support (03/15)
- 154 -
DEFAULT... If after 20 days, no answer has been filed, you may file a Motion for Default, Florida
Supreme Court Approved Family Law Form 12.922(a), with the clerk of court. Then, if you have filed all
of the required papers, you may call the clerk, family law intake staff, or judicial assistant to set a final
hearing. You must notify the other party of the hearing by using a Notice of Hearing (General), Florida
Supreme Court Approved Family Law Form 12.923, or other appropriate notice of hearing form.

UNCONTESTED... If the respondent files an answer that agrees with everything in your supplemental
petition or an answer and waiver, and you have complied with mandatory disclosure and filed all of the
required papers, you may call the clerk, family law intake staff, or judicial assistant to set a final hearing.
You must notify the other party of the hearing by using a Notice of Hearing (General), Florida Supreme
Court Approved Family Law Form 12.923, or other appropriate notice of hearing form.

CONTESTED... If the respondent files an answer or an answer and counterpetition, which disagrees
with or denies anything in your supplemental petition, and you are unable to settle the disputed issues,
you should file a Notice for Trial, Florida Supreme Court Approved Family Law Form 12.924, after you
have complied with mandatory disclosure and filed all of the required papers. Some circuits may require
the completion of mediation before a final hearing may be set. Then you should contact the clerk, family
law intake staff, or judicial assistant for instructions on how to set your case for trial (final hearing). If
the respondent files an answer and counterpetition, you should answer the counterpetition within 20
days using an Answer to Counterpetition, Florida Supreme Court Approved Family Law Form 12.903(d).

Where can I look for more information?

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions for Florida Supreme Court Approved Family Law Form 12.905(b), Supplemental
Petition for Modification of Child Support (03/15)
- 155 -
Special notes...
If you do not have the money to pay the filing fee, you may obtain an Application for Determination of
Civil Indigent Status from the clerk, fill it out, and the clerk will determine whether you are eligible to
have filing fees deferred.

With this form, you must also file the following:

 Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form
12.902(e). (If you do not know the other party’s income, you may file this worksheet
after his or her financial affidavit has been served on you.)
 Settlement Agreement, if you have reached an agreement on any or all of the issues.
Although there is no form for this in these Florida Family Law Forms, you may construct
a settlement agreement using the pertinent sections contained in Marital Settlement
Agreement for Dissolution of Marriage with Dependent or Minor Child(ren), Florida
Supreme Court Approved Family Law Form 12.902(f)(1).
 Notice of Social Security Number, Florida Supreme Court Approved Family Law Form
12.902(j), if not previously filed.
 Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or
(c). Certificate of Compliance with Mandatory Disclosure, Florida Family Law Rules of
Procedure Form 12.932. (This must be filed within 45 days of service of the
supplemental petition on the respondent, if not filed at the time of the supplemental
petition, unless you and the other party have agreed not to exchange these documents.)

Child Support... The court may order one parent to pay child support to assist the other parent in
meeting the child(ren)’s material needs. Both parents are required to provide financial support, but
one parent may be ordered to pay a portion of his or her support for the child(ren) to the other parent.
Florida has adopted guidelines for determining the amount of child support to be paid. These guidelines
are based on the combined income of both parents and take into account the financial contributions of
both parents. You must file a Family Law Financial Affidavit, Florida Family Law Rules of Procedure
Form 12.902(b) or (c), and the other parent will be required to do the same. From your financial
affidavits, you should be able to calculate the amount of child support that should be paid using the
Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e). Because
the child support guidelines take several factors into consideration, change over time, and vary from
state to state, your child support obligation may be more or less than that of other people in seemingly
similar situations.

Temporary Relief... If you need temporary relief regarding child support, you may file a Motion for
Temporary Support and Time-Sharing with Dependent or Minor Child(ren), Florida Supreme Court
Approved Family Law Form 12.947(a). For more information, see the instructions for that form.

Instructions for Florida Supreme Court Approved Family Law Form 12.905(b), Supplemental
Petition for Modification of Child Support (03/15)
- 156 -
before a notary public or deputy clerk. Any issues on which you are unable to agree will be considered
contested and settled by the judge at the final hearing.

Final Judgment Form... These family law forms contain a Supplemental Final Judgment Modifying
Child Support, Florida Supreme Court Approved Family Law Form 12.993(b), which the judge may use.
You should check with the clerk, family law intake staff, or judicial assistant to see if you need to bring it
with you to the hearing. If so, you should type or print the heading, including the circuit, county, case
number, division, and the parties’ names, and leave the rest blank for the judge to complete at your
hearing or trial.

Nonlawyer... Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps
you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida
Family Law Rules of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill
out these forms also must put his or her name, address, and telephone number on the bottom of the
last page of every form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.905(b), Supplemental
Petition for Modification of Child Support (03/15)
- 157 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
,
Petitioner,

and

,
Respondent.

SUPPLEMENTAL PETITION FOR MODIFICATION OF CHILD SUPPORT
I, {full legal name} , being sworn, certify that the
following information is true:

1. The parties to this action were granted a final judgment _____ of dissolution of marriage
_____ of paternity _____ for support unconnected with a dissolution of marriage _____ Other
[describe] ________________________________on {date} ____________________________.
A copy of the final judgment and any modification(s) is attached.

2. Paragraph(s) of the _____ final judgment or _____ most recent modification
thereof establishes the present child support at $ every _____week _____other
week _____ month, beginning on {date} _________________.

3. Since the final judgment or most recent modification thereof, there has been a substantial
change in circumstances, requiring a modification in child support. This change in circumstance
is as follows: {explain} ____________________________________________________________

4. I ask the Court to modify child support as follows: {explain} ______________________________

Florida Supreme Court Approved Family Law Form 12.905(b), Supplemental Petition for
Modification of Child Support (03/15)
- 158 -
.
5. This change is in the best interests of the child(ren) because: {explain} _____________________

6. A completed Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form
12.902(b) or (c), is _____, or _____will be, filed.

7. If not previously filed in this case, a completed Notice of Social Security Number, Florida
Supreme Court Approved Family Law Form 12.902(j), is filed.

8. A Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e),
_____ is, or _____ will be, filed.

9. Other:

_____.

Dated:
Signature of Petitioner
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es):____________________
_____________________________________________
STATE OF FLORIDA
COUNTY OF ___________________________

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

[Print, type, or stamp commissioned name of notary or deputy clerk.]
__ Personally known
__ Produced identification
Type of identification produced
Florida Supreme Court Approved Family Law Form 12.905(b), Supplemental Petition for
Modification of Child Support (03/15)
- 159 -
IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the Petitioner.
This form was completed with the assistance of:
{name of individual} ________________________________________________________________ ,
{name of business} __________________________________________________________________ ,
{address} ______________________________________________________________ ,
{city} ____________,{state} _______,{zip code}_____________, {telephone number} .

Florida Supreme Court Approved Family Law Form 12.905(b), Supplemental Petition for
Modification of Child Support (03/15)
- 160 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.905(c),
SUPPLEMENTAL PETITION FOR MODIFICATION OF ALIMONY (03/15)
When should this form be used?

This form should be used when you are asking the court to change a current court-ordered alimony
obligation. The court can change an order for temporary, permanent periodic, durational, and
rehabilitative alimony if the judge finds that there has been a substantial change in the circumstances
of the parties. Lump sum and bridge-the-gap alimony cannot be modified.

This form should be typed or printed in black ink. After completing this form, you should sign the form
before a notary public or deputy clerk. You should file this form in the county where the original order
was entered. If the order was entered in another state, or if the respondent lives in another state, you
should speak with an attorney about where to file this form. You should file the original with the clerk
of the circuit court and keep a copy for your records. Because you are filing the petition in this
proceeding, you are also referred to as the petitioner and your spouse as the respondent.

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?

For your case to proceed, you must properly notify the other party in your case of the supplemental
petition. Because this petition concerns alimony, you should use personal service. If the other party is
in the military service of the United States, additional steps for service may be required. See, for
example, Memorandum for Certificate of Military Service, Florida Supreme Court Approved Family Law
Form 12.912(a) and Affidavit of Military Service, Florida Supreme Court Approved Family Law Form
12.912(b). In sum, the law regarding constructive service and service on an individual in the military
service is very complex and you may wish to consult an attorney regarding this issue.

If personal service is used, the other party has 20 days to answer after being served with your
supplemental petition. Your case will then generally proceed in one of the following three ways:

DEFAULT... If after 20 days, no answer has been filed, you may file a Motion for Default, Florida
Supreme Court Approved Family Law Form 12.922(a), with the clerk of court. Then, if you have filed all
of the required papers, you may call the clerk, family law intake staff, or judicial assistant to set a final
hearing. You must notify the other party of the hearing by using a Notice of Hearing (General), Florida
Supreme Court Approved Family Law Form 12.923, or other appropriate notice of hearing form.

Instructions for Florida Supreme Court Approved Family Law Form 12.905(c), Supplemental
Petition for Modification of Alimony (03/15)
- 161 -
UNCONTESTED... If the respondent files an answer that agrees with everything in your supplemental
petition or an answer and waiver, and you have complied with mandatory disclosure and filed all of the
required papers, you may call the clerk, family law intake staff, or judicial assistant to set a final hearing.
You must notify the other party of the hearing by using a Notice of Hearing (General), Florida Supreme
Court Approved Family Law Form 12.923, or other appropriate notice of hearing form.

CONTESTED... If the respondent files an answer or an answer and counterpetition, which disagrees
with or denies anything in your supplemental petition, and you are unable to settle the disputed issues,
you should file a Notice for Trial, Florida Supreme Court Approved Family Law Form 12.924, after you
have complied with mandatory disclosure and filed all of the required papers. Some circuits may require
the completion of mediation before a final hearing may be set. Then you should contact the clerk, family
law intake staff, or judicial assistant for instructions on how to set your case for trial (final hearing). If
the respondent files an answer and counterpetition, you should answer the counterpetition within 20
days using an Answer to Counterpetition, Florida Supreme Court Approved Family Law Form 12.903(d).

Where can I look for more information?

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions for Florida Supreme Court Approved Family Law Form 12.905(c), Supplemental
Petition for Modification of Alimony (03/15)
- 162 -
Special notes...

With this form you must also file the following and serve a copy on the other party:

 Settlement Agreement, if you have reached an agreement on any or all of the issues.
Although there is no form for this in these Florida Family Law Forms, you may construct
a settlement agreement using the pertinent sections contained in Marital Settlement
Agreement for Dissolution of Marriage with Dependent or Minor Child(ren), Florida
Supreme Court Approved Family Law Form 12.902(f)(1), or Marital Settlement
Agreement for Dissolution of Marriage with No Dependent or Minor Child(ren), Florida
Supreme Court Approved Family Law Form 12.902(f)(2).

 Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or
(c).

 Certificate of Compliance with Mandatory Disclosure, Florida Family Law Rules of
Procedure Form 12.932. (This must be filed within 45 days of service of the
supplemental petition on the other party, if not filed at the time of the supplemental
petition, unless you and the other party have agreed not to exchange these documents.)

Alimony... In order to modify an order for alimony, a judge must find that there has been a substantial
change in circumstances.

Temporary Relief... If you need temporary relief regarding modification of alimony, you may file a
Motion for Temporary Support with Dependent or Minor Child(ren), Florida Supreme Court Approved
Family Law Form 12.947(a), or Motion for Temporary Support with No Dependent or Minor Child(ren),
Florida Supreme Court Approved Family Law Form 12.947(d), whichever is appropriate. For more
information, see the instructions for those forms.

Settlement Agreement... If you and the respondent are able to reach an agreement on any or all of the
issues, you should file a Settlement Agreement. Although there is no form for this in these Florida
Family Law Forms, you may construct a settlement agreement using the pertinent sections contained in
Marital Settlement Agreement for Dissolution of Marriage with Dependent or Minor Child(ren),
Florida Supreme Court Approved Family Law Form 12.902(f)(1), or Marital Settlement Agreement for
Dissolution of Marriage with No Dependent or Minor Child(ren), Florida Supreme Court Approved
Family Law Form 12.902(f)(2). Both parties must sign this agreement before a notary public. Any issues
on which you are unable to agree will be considered contested and settled by the judge at the final
hearing.

Final Judgment Form... These family law forms contain a Supplemental Final Judgment Modifying
Alimony, Florida Supreme Court Approved Family Law Form 12.993(c), which the judge may use. You
should check with the clerk, family law intake staff, or judicial assistant to see if you need to bring it with
you to the hearing. If so, you should type or print the heading, including the circuit, county, case

Instructions for Florida Supreme Court Approved Family Law Form 12.905(c), Supplemental
Petition for Modification of Alimony (03/15)
- 163 -
number, division, and the parties’ names, and leave the rest blank for the judge to complete at your
hearing or trial.

Nonlawyer... Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps
you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida
Family Law Rules of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill
out these forms also must put his or her name, address, and telephone number on the bottom of the
last page of every form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.905(c), Supplemental
Petition for Modification of Alimony (03/15)
- 164 -
IN THE CIRCUIT COURT OF THE_________________________JUDICIAL CIRCUIT,
IN AND FOR _________________________________ COUNTY, FLORIDA

Case No.:
Division:
___________________________________,
Petitioner,

____________________________________,
Respondent.

SUPPLEMENTAL PETITION FOR MODIFICATION OF ALIMONY

I, {full legal name} _______________________________________, being sworn, certify that the
following information is true:

1. The parties to this action were granted a final judgment ( ) of dissolution of marriage ( ) for
support unconnected with a dissolution of marriage on {date} __________________________.
A copy of the final judgment and any modification(s) is attached.

2. Paragraph(s) ______________ of the _____ final judgment or _____ most recent modification
thereof establishes the present alimony at $ _____________ every _____ week _____other
week _____ month, beginning on {date} ___________________________.

3. Since the final judgment or most recent modification thereof, there has been a substantial
change in circumstances, requiring a modification in alimony. This change in circumstance is as
follows: {explain} ________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.

4. I ask the Court to modify alimony as follows: {explain} __________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Florida Supreme Court Approved Family Law Form 12.905(c), Supplemental Petition for
Modification of Alimony (03/15)
- 165 -
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.

5. A completed Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form
12.902(b) or (c), is _____ , or _____will be, filed.

6. Other: ________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Dated: ______________________ _____________________________________________
Signature of PETITIONER
Printed Name: _________________________________
Address: ______________________________________
City, State, Zip: _________________________________
Telephone Number: _____________________________
Fax Number: __________________________________
Designated E-mail Address(es): ___________________
_____________________________________________

STATE OF FLORIDA
COUNTY OF ____________________

Sworn to or affirmed and signed before me on ____________ by _______________________________.

_____________________________________________
NOTARY PUBLIC or DEPUTY CLERK

_____________________________________________
[Print, type, or stamp commissioned name of notary or deputy clerk.]
____ Personally known
____ Produced identification
Type of identification produced ________________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
Florida Supreme Court Approved Family Law Form 12.905(c), Supplemental Petition for
Modification of Alimony (03/15)
- 166 -
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent
This form was completed with the assistance of:
{name of individual} _______________________________________________________________ ,
{name of business}_________________________________________________________________ ,
{address} ________________________________________________________________________ ,
{city} ______________,{state} ______, {zip code}____________, {telephone number} ______________ .

Florida Supreme Court Approved Family Law Form 12.905(c), Supplemental Petition for
Modification of Alimony (03/15)
- 167 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY
LAW FORM 12.905(d)
SUPPLEMENTAL PETITION FOR TEMPORARY MODIFICATION OF
PARENTING ISSUES FOR CHILD(REN) OF PARENT ACTIVATED,
DEPLOYED, OR TEMPORARILY ASSIGNED TO MILITARY SERVICE
(03/15)

When should this form be used?

This form should be used when a parent seeks a temporary modification of an order establishing
custody, visitation, a parenting plan, or time-sharing schedule because the parent is activated,
deployed, or temporarily assigned to military service and the parent’s ability to comply with the
prior order (s) and time-sharing schedule is materially affected.

IMPORTANT INFORMATION REGARDING E-FILING

The Florida Rules of Judicial Administration now require that all petitions, pleadings, and
documents be filed electronically except in certain circumstances. Self-represented litigants
may file petitions or other pleadings or documents electronically; however, they are not
required to do so. If you choose to file your pleadings or other documents electronically, you
must do so in accordance with Florida Rule of Judicial Administration 2.525, and you must follow
the procedures of the judicial circuit in which you file. The rules and procedures should be
carefully read and followed.

What should I do next?

Instructions for Florida Supreme Court Approved Family Law Form 12.905(d),
Supplemental Petition for Temporary Modification of Parenting Issues for Child(ren) of
Parent Activated, Deployed, or Temporarily Assigned to Military Service (03/15)
- 168 -
Form 12.913(b). If the other party is in the military service of the United States, additional steps
for service may be required. See, for example, Memorandum for Certificate of Military Service,
Florida Supreme Court Approved Family Law Form 12.912(a). In sum, the law regarding
constructive service and service on an individual in the military service is very complex and you
may wish to consult an attorney regarding these issues.

If personal service is used, the other party has 20 days to answer after being served with your
supplemental petition. Your case will then generally proceed in one of the following three ways:

DEFAULT... If after 20 days, no answer has been filed, you may file a Motion for Default, Florida
Supreme Court Approved Family Law Form 12.922(a), with the clerk of court. Then, if you have
filed all of the required papers, you may call the clerk, family law intake staff, or judicial
assistant to set a final hearing. You must notify the other party of the hearing by using a Notice
of Hearing (General), Florida Supreme Court Approved Family Law Form 12.923, or other
appropriate notice of hearing form.

UNCONTESTED... If the respondent files an answer that agrees with everything in your
supplemental petition or an answer and waiver, and you have complied with mandatory
disclosure and filed all of the required papers, you may call the clerk, family law intake staff, or
judicial assistant to set a final hearing. You must notify the other party of the hearing by using a
Notice of Hearing (General), Florida Supreme Court Approved Family Law Form 12.923, or other
appropriate notice of hearing form.

CONTESTED... If the respondent files an answer or an answer and counterpetition, which
disagrees with or denies anything in your supplemental petition, and you are unable to settle
the disputed issues, you should file a Notice for Trial, Florida Supreme Court Approved Family
Law Form 12.924, after you have complied with mandatory disclosure and filed all of the
required papers. Some circuits may require the completion of mediation before a final hearing
may be set. Then you should contact the clerk, family law intake staff, or judicial assistant for
instructions on how to set your case for trial (final hearing). If the respondent files an answer
and counterpetition, you should answer the counterpetition within 20 days using an Answer to
Counterpetition, Florida Supreme Court Approved Family Law Form 12.903(d).

Where can I look for more information?

Before proceeding, you should read General Information for Self-Represented Litigants found
at the beginning of these forms. The words that are in “bold underline” in these instructions
are defined there. For further information, see section 61.13002, Florida Statutes.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions for Florida Supreme Court Approved Family Law Form 12.905(d),
Supplemental Petition for Temporary Modification of Parenting Issues for Child(ren) of
Parent Activated, Deployed, or Temporarily Assigned to Military Service (03/15)
- 169 -
After the initial service of process of the petition or supplemental petition by the Sheriff or
certified process server, the Florida Rules of Judicial Administration now require that all
documents required or permitted to be served on the other party must be served by electronic
mail (e-mail) except in certain circumstances. You must strictly comply with the format
requirements set forth in the Rules of Judicial Administration.

To serve and receive documents by e-mail, you must designate your e-mail addresses by using
the Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family
Law Form 12.915, and you must provide your e-mail address on each form on which your
signature appears. Please CAREFULLY read the rules and instructions for: Certificate of Service
(General), Florida Supreme Court Approved Family Law Form 12.914; Designation of Current
Mailing and E-mail Address, Florida Supreme Court Approved Family Law Form 12.915; and
Florida Rule of Judicial Administration 2.516.

Special notes...

If you do not have the money to pay the filing fee, you may obtain an Application for
Determination of Civil Indigent Status from the clerk, fill it out, and the clerk will determine
whether you are eligible to have filing fees deferred.

With this form, you must also file the following:

 Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida
Supreme Court Approved Family Law Form 12.902(d).
 Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e),
if you are seeking modification of the child support obligation. (If you do not know the other
party’s income, you may file this worksheet after his or her financial affidavit has been
served on you.)
 Settlement Agreement, if you have reached an agreement on any or all of the issues.
Although there is no form for this in these Florida Family Law Forms, you may construct a
settlement agreement using the pertinent sections contained in Marital Settlement
Agreement for Dissolution of Marriage with Dependent or Minor Child(ren), Florida
Supreme Court Approved Family Law Form 12.902(f)(1).
 Notice of Social Security Number, Florida Supreme Court Approved Family Law Form
12.902(j), if not previously filed.
 Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or (c),
if you are seeking modification of the child support obligation.
 Parenting Plan, Florida Supreme Court Approved Family Law Form, 12.995(a), (b), or (c). If
the parties have reached an agreement, a signed and notarized Parenting Plan should be
attached. If you have not reached an agreement, a proposed Parenting Plan may be filed.

Instructions for Florida Supreme Court Approved Family Law Form 12.905(d),
Supplemental Petition for Temporary Modification of Parenting Issues for Child(ren) of
Parent Activated, Deployed, or Temporarily Assigned to Military Service (03/15)
- 170 -
 Certificate of Compliance with Mandatory Disclosure, Florida Family Law Rules of
Procedure Form 12.932, if you are seeking modification of the child support obligation. (This
must be filed within 45 days of service of the supplemental petition on the respondent, if
not filed at the time of the supplemental petition, unless you and the other party have
agreed not to exchange these documents.)

Temporary Judgment Form... These family law forms contain a Supplemental Temporary
Judgment Modifying Parenting Issues for Children of a Parent Activated, Deployed or
Temporarily Assigned to Military Service Florida Supreme Court Approved Family Law Form
12.993(d)), which the judge may use. You should check with the clerk, family law intake staff, or
judicial assistant to see if you need to bring it with you to the hearing. If so, you should type or
print the heading, including the circuit, county, case number, division, and the parties’ names,
and leave the rest blank for the judge to complete at your hearing or trial.

Nonlawyer... Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer
helps you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer,
Florida Family Law Rules of Procedure Form 12.900(a), before he or she helps you. A nonlawyer
helping you fill out these forms also must put his or her name, address, and telephone number
on the bottom of the last page of every form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.905(d),
Supplemental Petition for Temporary Modification of Parenting Issues for Child(ren) of
Parent Activated, Deployed, or Temporarily Assigned to Military Service (03/15)
- 171 -
IN THE CIRCUIT COURT OF THE _____________________ JUDICIAL CIRCUIT,
IN AND FOR ______________________________ COUNTY, FLORIDA

Case No: ________________________
Division: ________________________

_________________________________,
Petitioner,
And

_________________________________,
Respondent.

SUPPLEMENTAL PETITION FOR TEMPORARY MODIFICATION OF
PARENTING ISSUES FOR CHILD(REN) OF PARENT ACTIVATED,
DEPLOYED, OR TEMPORARILY ASSIGNED TO MILITARY SERVICE

I, {full legal name} ________________________________________, being sworn, certify that the
following information is true:

1. The parties to the action, {names} ____________________________________, were granted a final
judgment of [Choose one only] _____ dissolution of marriage _____ paternity on {date} ______________,
_____ other {describe}__________________________________________________________________.
A copy/copies of the final judgment or any modification(s) is/are attached.

2. Paragraph(s) ______ of the [Choose one only] _____ final judgment or _____ most recent
modification of it grants custody, primary care, or time-sharing of the minor child(ren), {name(s)}
____________________________, with {name of parent} _________________________________.

3. The parent, {name} _____________________________________, is: [Choose all that apply]
_____ activated
_____ deployed
_____ temporarily assigned to military service.

4. The parent, {name} _____________________________, is temporarily unable to continue the
current parenting plan and time-sharing schedule with the minor child(ren) during the period of
time that the parent is [Choose all that apply]
_____ activated
_____ deployed
_____ temporarily assigned to military service.

5. I ask the court to temporarily modify/amend the parental responsibility and time-sharing schedule
of the minor child(ren) during the period of time that the parent, {name} ___________________, is

Florida Supreme Court Approved Family Law Form 12.905(d), Supplemental Petition for
Temporary Modification of Parenting Issues for Child(ren) of Parent Activated, Deployed, or
Temporarily Assigned to Military Service (03/15)
- 172 -
[ Choose all that apply]
_____ activated
_____ deployed
_____ temporarily assigned to military service as follows:
{explain}_________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_________________________________________________________________________________.

6. This temporary modification/amendment is in the best interests of the child(ren).

7. I ask that the court adopt _____ the attached temporary Parenting Plan _____ time-sharing
schedule set forth below during the time that the parent is [Choose all that apply]
_____ activated
_____deployed
_____ temporarily assigned to military service:
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________.

8. If the requested modification/amendment is granted, Petitioner requests that child support be
temporarily modified/amended, consistent with the temporary modification/amendment of the
Parenting Plan and time-sharing schedule. A Child Support Guidelines Worksheet, Florida Family Law
Rules of Procedure Form 12.902(e) is, or will be, filed if a modification of child support is requested.

9. A completed Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or
(c) is filed with this Petition.

10. A completed Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida
Supreme Court Approved Family Law Form 12.902(d), is filed with this petition.

11. Other: ____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_______________________________________________________
___________________________________________________________________________

Dated: ______________________ _____________________________________________
Signature of PETITIONER

Florida Supreme Court Approved Family Law Form 12.905(d), Supplemental Petition for
Temporary Modification of Parenting Issues for Child(ren) of Parent Activated, Deployed, or
Temporarily Assigned to Military Service (03/15)
- 173 -
Printed Name: _________________________________
Address: _____________________________________
City, State, Zip: ________________________________
Telephone Number: _____________________________
Fax Number: __________________________________
Designated E-mail Address(es):____________________
_____________________________________________

STATE OF FLORIDA
COUNTY OF ____________________

Sworn to or affirmed and signed before me on ____________ by _______________________________.

_____________________________________________
NOTARY PUBLIC or DEPUTY CLERK

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the Petitioner.
This form was completed with the assistance of:
{name of individual} _______________________________________________________________ ,
{name of business}__________________________________________________________________ ,
{address} _________________________________________________________________________ ,
{city} ___________,{state} _______, {zip code}__________, {telephone number} ____________ .

Florida Supreme Court Approved Family Law Form 12.905(d), Supplemental Petition for
Temporary Modification of Parenting Issues for Child(ren) of Parent Activated, Deployed, or
Temporarily Assigned to Military Service (03/15)
- 174 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.910(b),
PROCESS SERVICE MEMORANDUM
(03/15)

When should this form be used?

You should use this form to give the sheriff’s department (or private process server) instructions for
serving the other party in your case with the Summons: Personal Service on an Individual, Florida
Family Law Rules of Procedure Form 12.910(a), and other papers to be served. On this form you can tell
the sheriff’s department the best times to find the person at work and/or at home. You can also include
a map to the other person’s home or work place to help the sheriff find the person and deliver the
summons. Do not forget to attach to the summons a copy of your initial petition and any other papers
you want personally served on the other party.

This form should be typed or printed in black ink. After completing this form, you should file the original
with the clerk of the circuit court in the county where your petition was filed and attach a copy to the
Summons: Personal Service on an Individual, Florida Family Law Rules of Procedure Form 12.910(a).
You should also keep a copy for your records.

IMPORTANT INFORMATION REGARDING E-FILING

Where can I look for more information?

Before proceeding, you should read General Information for Self-Represented Litigants found at the
beginning of these forms. You should read the instructions for Summons: Personal Service on an
Individual, Florida Family Law Rules of Procedure Form 12.910(a), for additional information.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions for Florida Supreme Court Approved Family Law Form 12.910(b), Process Service
Memorandum (03/15)
- 175 -
permitted to be served on the other party must be served by electronic mail (e-mail) except in certain
circumstances. You must strictly comply with the format requirements set forth in the Rules of Judicial
Administration.

Special notes...

If you fear that disclosing your address would put you in danger because you are the victim of sexual
battery, aggravated child abuse, stalking, aggravated stalking, harassment, aggravated battery, or
domestic violence, you should complete a Request for Confidential Filing of Address, Florida Supreme
Court Approved Family Law Form 12.980(h), file it with the clerk, and write confidential in the space
provided on the petition.

Nonlawyer. Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps
you fill out these forms, that person must give you a copy of Disclosure from Nonlawyer, Florida Family
Law Rules of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out
these forms also must put his or her name, address, and telephone number on the bottom of the last
page of every form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.910(b), Process Service
Memorandum (03/15)
- 176 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.: ________________________
Division: _________________________
,
Petitioner,
and

,
Respondent.

PROCESS SERVICE MEMORANDUM
TO: _____ Sheriff of _____ County, Florida; ________ Division
_____ Private process server:

Please serve the {name of document(s)}

in the above-styled cause upon:
Party: {full legal name}
Address or location for service:

Work Address:

If the party to be served owns, has, and/or is known to have guns or other weapons, describe what type
of weapon(s):

SPECIAL INSTRUCTIONS:

Dated: _______________________________________
Signature of Party
*Printed Name:
*Address:
*City, State, Zip:
*Telephone Number:
*Fax Number:
*Designated E-mail Address(es):___________________

Florida Supreme Court Approved Family Law Form 12.910(b), Process Service Memorandum
(03/15)
- 177 -
_____________________________________________

* Please see the Special Notes section in the instructions to this form regarding Florida Supreme Court
Approved Family Law Form 12.980(h), Request for Confidential Filing of Address, which may be used if
you need to keep your addresses or telephone numbers confidential for safety reasons.

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent
This form was completed with the assistance of:
{name of individual}______________________________________________________________ ,
{name of business} ________________________________________________________________ _,
{address} ____________________________ ,
{city} ______________,{state} ___, {zip code} ________,{telephone number} _________________.

Florida Supreme Court Approved Family Law Form 12.910(b), Process Service Memorandum
(03/15)
- 178 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY
LAW FORM 12.912(a)
MEMORANDUM FOR CERTIFICATE OF MILITARY SERVICE (03/15)
When should this form be used?

This form should be used if you KNOW OR DO NOT KNOW whether the other party in your case is on
active duty in a branch of the military service of the United States. “Active duty” includes reserve
personnel of the Army, Navy, Air Force, Marine Corps, and Coast Guard, and members of the Florida
National Guard who have been called to active duty for more than thirty (30) days. Even if you believe
that the other party has never or would never join the military, you must show the court proof that he
or she is not a member of the military. Therefore, you may need to use this form to provide the court
with such proof. See the instructions for an Affidavit of Military Service, Florida Supreme Court
Approved Family Law Form 12.912(b), for additional information.

Servicemembers Civil Relief Act (SCRA) Certificates:
For information on obtaining certificates of service or non-service under the Servicemembers Civil Relief
Act (SCRA)(formerly known as Soldiers’ and Sailors’ Civil Relief Act of 1940), please refer to the following
websites: http://www.defense.gov or www.dfas.mil.

You may also fill out this form and mail one copy to each of the military branches listed below. You may
be charged a service fee by each military service branch for their response. Please refer to the websites
and/or phone numbers listed below for help in determining the amount of each military branch’s fee
and to verify its current mailing address.

COAST GUARD: USCG Commander, Personnel Service Center, Attn: PSD-MR, 4200 Wilson Blvd., Suite
1100, Arlington VA 22203 Phone 1-866-772-8724 NOTE: All requests must be in writing.
www.uscg.mil/hq/cgpc/home/locator/html.
AIR FORCE: HQ AFPC/DPDXIDL, Attn: World Wide Locator, 550 C Street, West, Suite 50, Randolph AFB,
TX 78150-4752, Phone: (210) 565-2660, NOTE: Requests will be taken by phone. www.af.mil
NAVY: Bureau of Naval Personnel, PERS-312E, 5720 Integrity Drive, Millington, TN 38055-3120,
Phone: (901) 874-5111 www.npc.navy.mil NOTE: Requests will be taken by phone.
MARINE CORPS: CMC HQ (MMSB17), 2008 Elliot Road, Room 201, Quantico, VA 22134
Phone: (703)784-3941 NOTE: All requests must be in writing.
PUBLIC HEALTH SERVICE: Attn: Director, Division of Commissioned Corps Officer Support,
http://dcp.psc.gov/ad_search.asp NOTE: Please direct all inquiries to the website.
ARMY: Army World Wide Locator Service, Enlisted Records and Evaluation Center, 8899 East 56th
Street, Indianapolis, IN 46249-5301, Phone: (1-866) 771-6357, fax: (317) 510-3685 NOTE: All requests
must be in writing.
Instructions for Florida Supreme Court Approved Family Law Form 12.912(a), Memorandum
for Certificate of Military Service (03/15)
- 179 -
This form should be typed or printed in black ink. You should complete this form for each branch of the
United States’ military listed above, and mail the form to each branch with a check for the appropriate
amount and a stamped, self-addressed envelope. You should keep a copy of the form for your records.
After you have received a verification of military status from each branch, you will need to attach those
verifications to an Affidavit of Military Service, Florida Supreme Court Approved Family Law Form
12.912(b), for filing with the clerk.

Special notes...

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.912(a), Memorandum
for Certificate of Military Service (03/15)
- 180 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.: _____________________
Division: _______________________
,
Petitioner,

and

,
Respondent.

MEMORANDUM FOR CERTIFICATE OF MILITARY SERVICE
TO: ( ) USCG Commander, Personnel Service Center, Attn: PSD-MR, 4200 Wilson Blvd, Suite
1100, Arlington, VA 22203
( ) HQ AFPC/DPDXIDL, Attn: World Wide Locator, 550 C. Street West, Suite 50, Randolph
AFB, TX 78150-4752
( ) Bureau of Naval Personnel, PERS-312E, 5720 Integrity Drive, Millington, TN 38055-3120
( ) CMC, HQ, (MMSB17), 2008 Elliot Road, Room 201, Quantico, VA 22134
( ) Public Health Service: Attn: Director, Division of Commissioned Corps Officer Support
http://dcp.psc.gov/ad_search.asp
( ) Army World Wide Locator Service, Enlisted Records and Evaluation Center, 8899 East 56th
Street, Indianapolis, IN 46249-5301

RE:
{Name of Respondent} {Respondent’s Social Security Number}

This case involves a family matter. It is imperative that a determination be made whether the above-
named individual, who has an interest in these proceedings, is presently in the military service of the
United States, and the dates of induction and discharge, if any. This information is requested under the
Servicemembers Civil Relief Act (formerly known as Soldiers’ and Sailors’ Civil Relief Act of 1940). Please
supply verification as soon as possible. My check for $ ___ for your search fee and a self-
addressed, stamped envelope are enclosed.

Florida Supreme Court Approved Family Law Form 12.912(a), Memorandum for Certificate of
Military Service (03/15)
- 181 -
Dated: ______________________________________
Signature of Petitioner
Printed Name: _________________________
Address: _____________________________
City, State, Zip: ________________________
Telephone Number: ____________________
Fax Number: _________________________
Designated E-mail Address(es):____________
_____________________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the Petitioner.
This form was completed with the assistance of:
{name of individual} ________________________________________________________________ ,
{name of business}_________________________________________________________________ ,
{address}________________________________________________________________________ ,
{city}__________________, {state}____,{zip code}________, {telephone number} _______________.

Florida Supreme Court Approved Family Law Form 12.912(a), Memorandum for Certificate of
Military Service (03/15)
- 182 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.912(b),
AFFIDAVIT OF MILITARY SERVICE (03/15)

When should this form be used?

An Affidavit of Military Service is required in every case where the Respondent has not filed an answer
or appearance. The purpose is to protect the men and women serving in the U.S. military from having a
court judgment entered against them without first receiving notice of the lawsuit and a chance to
defend the case.

You should use this form when ALL of the following statements are true:

 The other person in your case has been served, whether by personal service or constructive service.
 The other person in your case has not responded to your petition.
 You are requesting that the court enter a default judgment against the other person.

This form should be typed or printed in black ink. After completing this form, you should sign the form
before a notary public or deputy clerk. You must file the original of this form with the clerk of the
circuit court when you file your Motion for Default, Florida Supreme Court Approved Family Law Form
12.922(a). You must also attach copies of all verifications of nonmilitary service that you received from
each branch of the United States’ military service. You should keep a copy for your records.

IMPORTANT INFORMATION REGARDING E-FILING

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

After the initial service of process of the petition or supplemental petition by the Sheriff or certified
process server, the Florida Rules of Judicial Administration now require that all documents required or
permitted to be served on the other party must be served by electronic mail (e-mail) except in certain
circumstances. You must strictly comply with the format requirements set forth in the Rules of Judicial
Administration.
Instructions for Florida Supreme Court Approved Family Law Form 12.912(b), Affidavit of
Military Service (03/15)
- 183 -
SELF-REPRESENTED LITIGANTS MAY SERVE DOCUMENTS BY E-MAIL; HOWEVER, THEY ARE NOT
REQUIRED TO DO SO. If a self-represented litigant elects to serve and receive documents by e-mail, the
procedures must always be followed once the initial election is made.

Special notes...

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.912(b), Affidavit of
Military Service (03/15)
- 184 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.: ___________________
Division: ___________________
,
Petitioner,

and

,
Respondent.

AFFIDAVIT OF MILITARY SERVICE
I, {full legal name} _____________________________________________________ , am the Petitioner
in this case. To support my application for a default judgment and to comply with the Servicemembers
Civil Relief Act (SCRA) (formerly known as Soldiers’ and Sailors’ Civil Relief Act of 1940), I swear or affirm
that the following information is true:
{Please choose only one}

1. _____I know of my own personal knowledge that the Respondent IS on active duty in the military
service of the United States.

2. _____ I know of my own personal knowledge that Respondent IS NOT now on active duty in the
military service of the United States, nor has the Respondent been on active military service of the
United States within a period of thirty (30) days immediately before this date. “Active Service”
includes reserve members of the Army, Navy, Air Force, Coast Guard, and Marines who have been
ordered to report for active duty and members of the Florida National Guard who have been
ordered to report to active duty for a period of more than thirty (30) days.

3. _____ I have contacted the military services of the United States and the U.S. Public Health Service
and have obtained certificates showing that the Respondent is not on active duty status. These
certificates are attached.

4. _____ I have attempted to determine the military status of the Respondent, but do not have
sufficient information. This is what I have done to determine whether or not Respondent is on
active duty in the United States military:
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________

Florida Supreme Court Approved Family Law Form 12.912(b), Affidavit of Military Service
(03/15)
- 185 -
__________________________________________________________________________________
_________________________________________________________________________________.
I have no reason to believe that s/he is on active duty at this time.
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
affidavit and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.

Dated:_______________________ _______________________________________
Signature of Petitioner
Printed Name: _______________________________
Address:____________________________________
City, State, Zip: ______________________________
Telephone Number: __________________________
Fax Number: ________________________________
Designated E-mail Address(es):__________________
___________________________________________

STATE OF FLORIDA
COUNTY OF _______________________

Sworn to or affirmed and signed before me on __________ by _________________________________.

_____________________________________________
NOTARY PUBLIC or DEPUTY CLERK
_____________________________________________
[Print, type, or stamp commissioned name of notary or clerk.]
_____ Personally known
_____ Produced identification
_____ Type of identification produced ____________________________________.

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the Petitioner.
This form was completed with the assistance of:
{name of individual}, _______________________________________________________________ ,
{name of business}___________________________________________________________________ ,
{address} __________________________________________________________________________ ,
Florida Supreme Court Approved Family Law Form 12.912(b), Affidavit of Military Service
(03/15)
- 186 -
{city}_________________,{state} _____, {zip code}_________,{telephone number}________________ .

Florida Supreme Court Approved Family Law Form 12.912(b), Affidavit of Military Service
(03/15)
- 187 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.913(a)(1)
NOTICE OF ACTION FOR DISSOLUTION OF MARRIAGE
(NO CHILD OR FINANCIAL SUPPORT)
(03/15)

When should this form be used?
This form may be used to obtain constructive service (also called service by publication) in a dissolution
of marriage case that does not involve a minor child or financial support if you do not know where your
spouse lives or if your spouse lives outside Florida and you are unable to obtain personal service.
Constructive notice will allow the court to dissolve the marriage, but personal service is required before
a court can order payment of financial support, such as spousal support (alimony) or costs. If you are
asking the court to decide how real or personal property located in Florida should be divided, the Notice
of Action must include a specific description of the property. If you use constructive service, the court
can grant only limited relief because its jurisdiction is limited. This is a complicated area of the law and
you should consult an attorney before using constructive service.

You should complete this form by typing or printing the appropriate information in black ink. You
should insert your spouse’s name and last known address and then file this form with the clerk of the
circuit court in the county where your petition for dissolution of marriage was filed. You must also
complete and file an Affidavit of Diligent Search and Inquiry, Florida Family Law Rules of Procedure
Form 12.913(b). You should keep a copy for your records.

After the Affidavit of Diligent Search and Inquiry, Florida Family Law Rules of Procedure Form
12.913(b), is filed, the clerk will sign this form. The form must then be given to a qualified local
newspaper in the county where the case is pending to be published once each week for four consecutive
weeks. When in doubt, ask the clerk which newspapers in your area are “qualified.” The newspaper will
charge you for this service. If you cannot afford to pay the cost of publication of this notice in a qualified
newspaper, you may ask the clerk to post the notice at a place designated for such postings. You will
need to file an Application for Determination of Civil Indigent Status, which you can obtain from the
clerk. If the clerk determines that you cannot afford these costs, the clerk will post the notice of action.

IMPORTANT INFORMATION REGARDING E-FILING

Instructions for Florida Supreme Court Approved Family Law Form 12.913(a)(1), Notice of
Action for Dissolution of Marriage (No Child or Financial Support) (03/15)
- 188 -
Where can I look for more information?
Before proceeding, you should read “General Information for Self-Represented Litigants” found at the
beginning of these forms. For further information, see rule 12.070, Florida Family Law Rules of
Procedure, and chapter 49, Florida Statutes.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Special notes...
If the other party fails to respond to your petition within the time limit stated in the notice of action that
is published or posted, you are entitled to request a default. (See Motion for Default, Florida Supreme
Court Approved Family Law Form 12.922(a), and Default, Florida Supreme Court Approved Family Law
Form 12.922(b).)

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.913(a)(1), Notice of
Action for Dissolution of Marriage (No Child or Financial Support) (03/15)
- 189 -
IN THE CIRCUIT COURT OF THE ___________ JUDICIAL CIRCUIT,
IN AND FOR ____________________________________ COUNTY, FLORIDA

Case No._______________________________
Division: ________________________________
__________________________________ ,
Petitioner

and

__________________________________ ,
Respondent.

NOTICE OF ACTION FOR DISSOLUTION OF MARRIAGE
(NO CHILD OR FINANCIAL SUPPORT)
TO: {name of Respondent} _______________________________________________________________
{Respondent’s last known address} ________________________________________________________

YOU ARE NOTIFIED that an action for dissolution of marriage has been filed against you and that you are
required to serve a copy of your written defenses, if any, to it on {name of Petitioner}
_____________________________________________________________________________________,
whose address is _______________________________________________________________________
on or before {date} ______________, and file the original with the clerk of this Court at {clerk’s address}
____________________________________________________________________________________,
before service on Petitioner or immediately thereafter. If you fail to do so, a default may be entered
against you for the relief demanded in the petition.

The action is asking the court to decide how the following real or personal property should be divided:
{insert “none” or, if applicable, the legal description of real property, a specific description of personal
property, and the name of the county in Florida where the property is located}
___________________________________________________________________________________

Copies of all court documents in this case, including orders, are available at the Clerk of the Circuit
Court’s office. You may review these documents upon request.

You must keep the Clerk of the Circuit Court’s office notified of your current address. (You may file
Designation of Current Mailing and E-Mail Address, Florida Supreme Court Approved Family Law Form
12.915.) Future papers in this lawsuit will be mailed or e-mailed to the address(es) on record at the
clerk’s office.

WARNING: Rule 12.285, Florida Family Law Rules of Procedure, requires certain automatic disclosure
of documents and information. Failure to comply can result in sanctions, including dismissal or
striking of pleadings.

Florida Supreme Court Approved Family Law Form 12.913(a)(1), Notice of Action for Dissolution
of Marriage (No Child or Financial Support) (03/15)
- 190 -
Dated: ______________________ CLERK OF THE CIRCUIT COURT

By: ___________________________________________
Deputy Clerk

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the Petitioner.
This form was completed with the assistance of:
{name of individual} _____________________________________________________________ ,
{name of business} _______________________________________________________________ ,
{address} ______________________________________________________________________ ,
{city} _____________, {state} ____, {zip code}________, {telephone number}_________________ .

Florida Supreme Court Approved Family Law Form 12.913(a)(1), Notice of Action for Dissolution
of Marriage (No Child or Financial Support) (03/15)
- 191 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY
LAW FORM 12.913(a)(2)
NOTICE OF ACTION FOR FAMILY CASES WITH MINOR CHILD(REN)
(03/15)

When should this form be used?

This form may be used to obtain constructive service (also called service by publication) in an
action involving a parenting plan for a minor child under chapter 61, Florida Statutes; an action
to determine temporary custody by extended family under chapter 751, Florida Statutes; and
termination of a legal father’s parental rights when another man is alleged to be the biological
father. "Parenting plan" means a document created to govern the relationship between the
parents relating to decisions that must be made regarding the minor child and must contain a
time-sharing schedule for the parents and child. Section 61.046(14), Florida Statutes. You may
use constructive service if you do not know where the other party lives or if the other party lives
outside Florida and you are unable to obtain personal service. Constructive notice will allow the
court to grant the relief requested, but personal service is required before a court can order
payment or termination of child support, spousal support (alimony), or costs. If you are asking
the court to decide how real or personal property located in Florida should be divided, the
Notice of Action must include a specific description of the property. If you use constructive
service, the court can grant only limited relief because its jurisdiction is limited. This is a
complicated area of the law and you should consult an attorney before using constructive
service.

You should complete this form by typing or printing the appropriate information in black ink.
You must insert the other party’s name and last known address and then file this form with the
clerk of the circuit court in the county where your petition was filed. You must also complete
and file an Affidavit of Diligent Search and Inquiry. Use Florida Family Law Rules of Procedure
Form 12.913(b) unless you are serving the legal father in a paternity case where another man is
alleged to be the biological father, in which case, you must use Form 12.913(c). You should keep
a copy for your records.

IMPORTANT INFORMATION REGARDING E-FILING

The Florida Rules of Judicial Administration now require that all petitions, pleadings, and
documents be filed electronically except in certain circumstances. Self-represented litigants
may file petitions or other pleadings or documents electronically; however, they are not
required to do so. If you choose to file your pleadings or other documents electronically, you
must do so in accordance with Florida Rule of Judicial Administration 2.525, and you must follow
the procedures of the judicial circuit in which you file. The rules and procedures should be
carefully read and followed.

After the Affidavit of Diligent Search and Inquiry, Family Law Rules of Procedure Form
12.913(b) or 12.913(c), is filed, the clerk will sign this form. You will need to publish notice once
each week for four consecutive weeks in a “qualified” newspaper in the county where the case

Instructions for Florida Supreme Court Approved Family Law Form 12.913(a)(2), Notice of Action For
Family Cases With Minor Child(ren) (03/15)
- 192 -
is pending. When in doubt, ask the clerk which newspapers are “qualified.” The newspaper will
charge you for this service. If you cannot afford to pay the cost of publishing this notice, you
may ask the clerk to post the notice at a place designated for such postings. You will need to file
an Application for Determination of Civil Indigent Status, which you can obtain from the clerk.
If the clerk determines that you cannot afford these costs, the clerk will post the notice of
action. If your case involves termination of a legal father's parental rights when another man is
alleged to be the biological father, you need to publish the notice only in the county where the
legal father was last known to have resided. You are responsible for locating a “qualified”
newspaper in the county where the other party last resided and paying the cost of publication.

Where can I look for more information?

Before proceeding, you should read “General Information for Self-Represented Litigants”
found at the beginning of these forms. For further information, see rule 12.070, Florida Family
Law Rules of Procedure, rule 1.070, Florida Rules of Civil Procedure, sections 61.501–61.542,
Florida Statutes and chapter 49, Florida Statutes.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

To serve and receive documents by e-mail, you must designate your e-mail addresses by using
the Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family
Law Form 12.915, and you must provide your e-mail address on each form on which your
signature appears. Please CAREFULLY read the rules and instructions for: Certificate of Service
(General), Florida Supreme Court Approved Family Law Form 12.914; Designation of Current
Mailing and E-mail Address, Florida Supreme Court Approved Family Law Form 12.915; and
Florida Rule of Judicial Administration 2.516.

Special notes...

If the other party fails to respond to your petition within the time limit stated in the notice of
action that is published or posted, you are entitled to request a default. (See Motion for
Default, Florida Supreme Court Approved Family Law Form 12.922(a), and Default, Florida
Supreme Court Approved Family Law Form 12.922(b).)

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill
out these forms, that person must give you a copy of Disclosure from Nonlawyer, Florida Family
Law Rules of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill
Instructions for Florida Supreme Court Approved Family Law Form 12.913(a)(2), Notice of Action For
Family Cases With Minor Child(ren) (03/15)
- 193 -
out these forms also must put his or her name, address, and telephone number on the bottom
of the last page of every form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.913(a)(2), Notice of Action For
Family Cases With Minor Child(ren) (03/15)
- 194 -
IN THE CIRCUIT COURT OF THE __________________ JUDICIAL CIRCUIT,
IN AND FOR _________________________ COUNTY, FLORIDA

Case No.: _______________________________
Division: ________________________________
__________________________________ ,
Petitioner

and

_________________________________ ,
Respondent.

NOTICE OF ACTION FOR
{Specify action} _____________________________________________________________________

TO: {name of Respondent} _______________________________________________________________
{Respondent’s last known address} ________________________________________________________

YOU ARE NOTIFIED that an action for {identify the type of case} ________________________has been
filed against you and that you are required to serve a copy of your written defenses, if any, to it on
{name of Petitioner} ____________________________________________________________________,
whose address is _______________________________________________________________________
on or before {date}_______________, and file the original with the clerk of this Court at {clerk’s address}
____________________________________________________________________________________
before service on Petitioner or immediately thereafter. If you fail to do so, a default may be entered
against you for the relief demanded in the petition.

{If applicable, insert the legal description of real property, a specific description of personal property, and
the name of the county in Florida where the property is located} ________________________________
____________________________________________________________________________________.

Copies of all court documents in this case, including orders, are available at the Clerk of the Circuit
Court’s office. You may review these documents upon request.

Florida Supreme Court Approved Family Law Form 12.913(a)(2), Notice of Action For Family Cases With Minor
Child(ren) (03/15)
- 195 -
Dated: __________________. CLERK OF THE CIRCUIT COURT

By: ___________________________________
Deputy Clerk

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the Petitioner.
This form was completed with the assistance of:
{name of individual} _____________________________________________________________ ,
{name of business} _______________________________________________________________ ,
{address} ______________________________________________________________________ ,
{city} _____________, {state} ____, {zip code}________, {telephone number}_________________ .

Florida Supreme Court Approved Family Law Form 12.913(a)(2), Notice of Action For Family Cases With Minor
Child(ren) (03/15)
- 196 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.914
CERTIFICATE OF SERVICE
(03/15)

When should this form be used?

After a petition or supplemental petition has been properly served (through either personal service or
constructive service), both parties must serve copies of all additional documents or papers they file with
the clerk on the other party, or his or her attorney, if he or she has one. Each time you file a document,
you must certify that you provided the other party with a copy. Many of the Florida Family Law Forms
already have a place above the signature line for this certification. It looks like this:

I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-
delivered to the person(s) listed below on {date} ______________________.

Other party or his/her attorney:
Name:
Address:
City, State, Zip:
Fax Number:
Designated E-mail Address(es):_________________
__________________________________________

If a form you are filing has a certificate, you do not need to file a separate Certificate of Service, Florida
Supreme Court Approved Family Law Form 12.914. However, each time you file a document that does
not have a certificate like the one above, you must file a Certificate of Service, Florida Supreme Court
Approved Family Law Form 12.914, and serve a copy of the document on the other party.

This form should be typed or printed in black ink. After completing this form (giving the name of each
form, document, or paper filed), you should sign the form before a notary public or deputy clerk. You
should file the original with the clerk of the circuit court in the county where your case was filed and
keep a copy for your records.

IMPORTANT INFORMATION REGARDING E-FILING

Instructions for Florida Supreme Court Approved Family Law Form 12.914, Certificate of Service (03/15)
- 197 -
What should I do next?

The copy you are providing to the other party must be either mailed, e-mailed, or hand-delivered to the
opposing party or his or her attorney on the same day indicated on the certificate of service. If it is
mailed, it must be postmarked on the date indicated in the certificate of service.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Where can I look for more information?

Before proceeding, you should read General Information for Self-Represented Litigants found at the
beginning of these forms. For more information, see rule 1.080, Florida Rules of Civil Procedure and
rule 12.080, Florida Family Law Rules of Procedure.

Special notes

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill out these forms
Instructions for Florida Supreme Court Approved Family Law Form 12.914, Certificate of Service (03/15)
- 198 -
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.914, Certificate of Service (03/15)
- 199 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
,
Petitioner,

and

,
Respondent.

CERTIFICATE OF SERVICE
I certify that a copy of {name of document(s)}

was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the person listed below on
{date} .

Other party or his/her attorney:
Name:
Address:
City, State, Zip: _______
Fax Number:
Designated E-mail Address(es):______________________
_______________________________________________

Signature of Party
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es):______________________
________________________________________________

Florida Supreme Court Approved Family Law Form 12.914, Certificate of Service (03/15)
- 200 -
{name of
business}_______________________________________________________________________,
{address} ,
{city} __________________,{state} ____,{zip code}___________,{telephone number}
___________________.

Florida Supreme Court Approved Family Law Form 12.914, Certificate of Service (03/15)
- 201 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.915,
DESIGNATION OF CURRENT MAILING AND E-MAIL ADDRESS (03/15)
When should this form be used?

This form should be used to inform the clerk and the other party of your current mailing and e-mail
address(es) or any change of address. It is very important that the court and the other party in your
case have your correct address.

A party not represented by an attorney may choose to designate e-mail address(es) for service. A
primary and up to two secondary e-mail addresses can be designated. If you do so and the other party
is represented by an attorney or has also designated e-mail address(es) for service, e-mail will be the
exclusive means of service.

If there is any change in your mailing or e-mail address(es), you must complete a new form, file it with
the clerk, and serve a copy on any other party or parties in your case.

What should I do next?

This form should be typed or printed in black ink. After completing this form, you should file the original
with the clerk of the circuit court in the county where your case is filed and keep a copy for your
records. A copy of this form must be served on any other party in your case. Service must be in
accordance with Florida Rule of Judicial Administration 2.516.

IMPORTANT INFORMATION REGARDING E-FILING

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions for Florida Supreme Court Approved Family Law Form 12.915, Designation of Current Mailing and
E-mail Address (03/15)
- 202 -
circumstances. You must strictly comply with the format requirements set forth in the Rules of Judicial
Administration.

Where can I look for more information?

Special notes...

Instructions for Florida Supreme Court Approved Family Law Form 12.915, Designation of Current Mailing and
E-mail Address (03/15)
- 203 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
,
Petitioner,

and

,
Respondent.

DESIGNATION OF CURRENT MAILING AND E-MAIL ADDRESS
I, {full legal name} , being sworn, certify that
my current mailing address is: {Street}
{City} _______, {State} ____________ {Zip} _________________
{Telephone No.} __________ {Fax No.} ______________.

I designate as my current e-mail address(es):________________________________________________

_____________________________________________________________________________________

I understand that I must keep the clerk’s office and the opposing party or parties notified of my
current mailing and e-mail address(es) and that all future papers in this lawsuit will be served at the
address(es) on record at the clerk’s office.

I certify that a copy of this document was: ( ) e-mailed ( ) mailed ( ) faxed
( ) hand-delivered to the person(s) listed below on {date}__________________________.

Other party or his/her attorney:
Name: _____________________________
Address: ____________________________
City, State, Zip: _______________________
Fax Number: _________________________
Designated E-mail Address(es): ___________
__________________________________

Florida Supreme Court Approved Family Law Form 12.915, Designation of Current Mailing and E-mail Address
(03/15)
- 204 -
Dated: _______________ _____________________________________________

STATE OF FLORIDA
COUNTY OF
Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

_____________________________________________________________________________________
[Print, type, or stamp commissioned name of notary or clerk.]
_ Personally known
_ Produced identification
Type of identification produced

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent
This form was completed with the assistance of:
{name of individual} ______________________________________________________________ ,
{name of business} _______________________________________________________________ ,
{street} ______________________________________________ ,
{city} ,{state} __, {zip code}______,{telephone number}__________________ .

Florida Supreme Court Approved Family Law Form 12.915, Designation of Current Mailing and E-mail Address
(03/15)
- 205 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.921,
NOTICE OF HEARING (CHILD SUPPORT ENFORCEMENT HEARING
OFFICER)(03/15)

When should this form be used?

A child support enforcement hearing officer is an attorney who has been appointed by administrative
order of the court to take testimony and recommend decisions in cases involving the establishment,
enforcement, and/or modification of child support. If your case only involves issues pertaining to child
support, you cannot object to the referral of your case to a hearing officer.

Use this form anytime you have set a hearing before a child support enforcement hearing officer and
have been instructed to send notice of the hearing to the other party. Before you fill out this form, you
should coordinate a hearing time and date with the hearing officer and the other party. If the
Department of Revenue is a party to the case, you may need to schedule your hearing time with the
attorney for the Department of Revenue.

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?
A copy of this form must be mailed, e-mailed, or hand-delivered to the other party in your case.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions for Florida Supreme Court Approved Family Law Form 12.921, Notice of Hearing (Child Support
Enforcement Hearing Officer) (03/15)
- 206 -
circumstances. You must strictly comply with the format requirements set forth in the Rules of Judicial
Administration.

Where can I look for more information?

Before proceeding, you should read General Information for Self Represented Litigants found at the
beginning of these forms. For further information, See Rule 12.941, Florida Family Law Rules of
Procedure.

Special notes...

An attorney who has been appointed by the court to serve as a child support enforcement hearing
officer can also be appointed to serve as a general magistrate. If your case involves only child support
issues, your case may properly be referred to a general magistrate acting as a child support enforcement
hearing officer.

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.921, Notice of Hearing (Child Support
Enforcement Hearing Officer) (03/15)
- 207 -
IN THE CIRCUIT COURT OF THE ____________________ JUDICIAL CIRCUIT,
IN AND FOR ____________________ COUNTY, FLORIDA

Case No.: __________________________
Division: ___________________________

______________________________________,
Petitioner,

and

_____________________________________,
Respondent.

NOTICE OF HEARING
(CHILD SUPPORT ENFORCEMENT HEARING OFFICER)
TO: {name of other party}: _______________________________________________________________
There will be a hearing before Child Support Enforcement Hearing Officer {name} __________________ ,
on {date} ________________, at {time} _____ m., in Room ______ of the _________________________
County Courthouse, on the following issues: ________________________________________________
____________________________________________________________________________________ .
_____ hour(s)/_____ minutes have been reserved for this hearing.

If the matter before the Child Support Enforcement Hearing Officer is a Motion for Civil
Contempt/Enforcement, FAILURE TO APPEAR AT THE HEARING MAY RESULT IN THE COURT ISSUING A
WRIT OF BODILY ATTACHMENT FOR YOUR ARREST. IF YOU ARE ARRESTED, YOU MAY BE HELD IN JAIL
UP TO 48 HOURS BEFORE A HEARING IS HELD.

This part to be filled out by the court or filled in with information you have obtained from the court:

If you are a person with a disability who needs any accommodation in order
to participate in this proceeding, you are entitled, at no cost to you, to the
provision of certain assistance. Please contact:
__________________________________________________________________
{identify applicable court personnel by name, address, and telephone number} at
least 7 days before your scheduled court appearance, or immediately upon
Florida Supreme Court Approved Family Law Form 12.921, Notice of Hearing (Child Support Enforcement Hearing
Officer) (03/15)
- 208 -
receiving this notification if the time before the scheduled appearance is less
than 7 days; if you are hearing or voice impaired, call 711.

If you are represented by an attorney or plan to retain an attorney for this matter, you should notify the
attorney of this hearing.

If this matter is resolved, the moving party shall contact the hearing officer’s office to cancel this
hearing.

I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-
delivered to the person(s) listed below on {date} ______________________.

Other party or his/her attorney:
Name: ________________________________________
Address: ______________________________________
City, State, Zip: _________________________________
Fax Number: ___________________________________
Designated E-mail Address(es):_____________________

_____________________________________________
Signature of Party
Printed Name: _________________________________
Address: ______________________________________
City, State, Zip: _________________________________
Telephone Number:_____________________________
Fax Number:___________________________________
Designated E-mail Address(es):____________________
_____________________________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent
This form was completed with the assistance of:
{name of individual} ___________________________________ ,
{name of business} ____________________________________________________________________ ,
{address} ___________________________________________________ ,
{city} ________________, {state} ____, {zip code}__________,{telephone number} ________________ .

Florida Supreme Court Approved Family Law Form 12.921, Notice of Hearing (Child Support Enforcement Hearing
Officer) (03/15)
- 209 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORMS 12.922(a), MOTION FOR DEFAULT, AND 12.922(b), DEFAULT
(03/15)

When should these forms be used?

If the other party has failed to file or serve any documents within 20 days after the date of service of
your petition, you may ask the clerk of the circuit court to enter a default against him or her by filling
out this form and filing it with the court. Generally, a default allows you to obtain an earlier final hearing
to finish your case. Once the default is signed by the clerk, you can request a trial or final hearing in your
case.

To obtain a default, you will need to complete Motion for Default, Florida Supreme Court Approved
Family Law Form 12.922(a). You will then need to file your motion for default along with the Default,
Florida Supreme Court Approved Family Law Form 12.922(b), so that the clerk can enter a default for
you if your motion is proper.

This form should be typed or printed in black ink. After completing this form, you should file the original
with the clerk of the circuit court in the county where you filed your petition and keep a copy for your
records.

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?

After the default has been entered, you must ask for a hearing, so that the judge can consider your
petition. To do this, you must contact the clerk’s office, family law intake staff, or judicial assistant to
schedule a hearing and file a Notice of Hearing (General), Florida Supreme Court Approved Family Law
Form 12.923, with the clerk. A copy of the notice of hearing must be mailed, e-mailed, or hand-delivered
to each party in the case. You must send a notice of final hearing to the defaulted party.

Instructions for Florida Supreme Court Approved Family Law Forms 12.922(a), Motion for Default, and 12.922(b),
Default (03/15)
- 210 -
IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Where can I look for more information?

Before proceeding, you should read General Information for Self-Represented Litigants found at the
beginning of these forms. For further information, see Florida Rules of Civil Procedure 1.500,
concerning defaults and Rule 1.140, concerning the time within which a party can file an answer or
other responsive pleading to a petition. See also Florida Family Law Rule of Procedure 12.080.

Special notes...

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Forms 12.922(a), Motion for Default, and 12.922(b),
Default (03/15)
- 211 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
,
Petitioner,

and

,
Respondent.

MOTION FOR DEFAULT

TO THE CLERK OF THE CIRCUIT COURT:

PLEASE ENTER A DEFAULT AGAINST RESPONDENT WHO HAS FAILED TO RESPOND TO THE PETITION.

I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-
delivered to the person(s) listed below on {date} ______________________.

Other party or his/her attorney:
Name:
Address:
City, State, Zip:
Fax Number:
Designated E-mail Address(es): _____________________

Signature of Petitioner
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:

Designated E-mail Address(es):_____________________

______________________________________________

Florida Supreme Court Approved Family Law Form 12.922(a), Motion for Default (03/15)
- 212 -
IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent
This form was prepared with the assistance of:
{name of individual} ____________________________________________________________________ ,
{name of business}
______________________________________________________________________ ,
{address}
______________________________________________ ,
{city} _____________, {state} __, {zip code}__________,{telephone number} .

Florida Supreme Court Approved Family Law Form 12.922(a), Motion for Default (03/15)
- 213 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR ________ COUNTY, FLORIDA

Case No.:
Division:
__________________________________,
Petitioner,

and

___________________________________,
Respondent.

DEFAULT

A default is entered in this action against Respondent for failure to serve or file a response or any paper
as is required by law.

Dated: _______
CLERK OF THE CIRCUIT COURT
(SEAL)
By:
Deputy Clerk

I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-
delivered to the person(s) listed below on {date}_____________________________________.
Other party or his/her attorney:
Name:
Address:
City, State, Zip:
Fax Number:
Designated E-mail Address(es): _____________________

Signature of Petitioner
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:

Designated E-mail Address(es):____________________________________________________________

Florida Supreme Court Approved Family Law Form 12.922(b), Default (03/15)
- 214 -
IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent
This form was completed with the assistance of:
{name of individual},____________________________________ ,
{name of business} _____________________________________________________________________ ,
{address} ,
{city} _______________,{state} ,{zip code}___________,{telephone number} .

Florida Supreme Court Approved Family Law Form 12.922(b), Default (03/15)
- 215 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.922(c),
MOTION TO SET ASIDE DEFAULT OR DEFAULT JUDGMENT
(03/15)
When should this form be used?

If a default or default judgment has been entered against you, and you believe, because of a mistake,
inadvertence, excusable neglect, newly discovered evidence, or fraud, that it should not have been
entered against you, you can use this form to request that the court set aside the default or default
judgment.

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?

After you file this form with the clerk and serve a copy on the other party in the case, you must schedule
a hearing so that the court can consider your motion. You should contact the clerk, family law intake
staff, or judicial assistant to schedule a hearing. Once you have scheduled the hearing date and time,
you will need to complete and send out a notice for that hearing. To do so, use Notice of Hearing
(General), Florida Supreme Court Approved Family Law Form 12.923, or other appropriate notice of
hearing form.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions for Florida Supreme Court Approved Family Law Form 12.922(c), Motion to Set Aside Default or
Default Judgment (03/15)
- 216 -
SELF-REPRESENTED LITIGANTS MAY SERVE DOCUMENTS BY E-MAIL; HOWEVER, THEY ARE NOT
REQUIRED TO DO SO. If a self-represented litigant elects to serve and receive documents by e-mail, the
procedures must always be followed once the initial election is made.

Where can I look for more information?

Before proceeding, you should read General Information for Self-Represented Litigants found at the
beginning of these forms. For further information, see Florida Family Law Rule of Procedure 12.540, and
Florida Rules of Civil Procedure 1.500(d) and 1.540(d).

Special notes...

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.922(c), Motion to Set Aside Default or
Default Judgment (03/15)
- 217 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
__________________________________,
Petitioner,

and

____________________________________,
Respondent.

MOTION TO SET ASIDE DEFAULT OR DEFAULT JUDGMENT

I, {full legal name} , request that the Court enter an order
to set aside the _____ Default _____ Default Judgment entered against me and that I be given the
opportunity to present my views.

The Court should do this because:

1. I became aware of this Default/Default Judgment on {date}
______________________________.

2. I found out about this in the following manner {explain how you found out}:

3. I did not answer or appear at the hearing because:

4. If I am given an opportunity, these are the defenses and arguments that I would like to tell the

Supreme Court Approved Family Law Form 12.922(c), Motion to Set Aside Florida Default or Default Judgment
(03/15)
- 218 -
court about:

I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-
delivered to the person(s) listed below on {date} .

Other party or his/her attorney:
Name:
Address:
City, State, Zip:
Fax Number:
Designated E-mail Address(es):______________________

Dated:

Signature of Respondent
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:

Designated E-mail Address(es):
__________________________________________________________________

STATE OF FLORIDA
COUNTY OF

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

Supreme Court Approved Family Law Form 12.922(c), Motion to Set Aside Florida Default or Default Judgment
(03/15)
- 219 -
[Print, type, or stamp commissioned name of notary or clerk.
Personally known
_ Produced identification
Type of identification produced

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent
This form was completed with the assistance of:
{name of individual} __________________________________________________________________ ,
{name of business} ____________________________________________________________________ ,
{address} ____________________________________________ ,
{city} _______________,{state}_____, {zip code}___________,{telephone number}_______________ .

Supreme Court Approved Family Law Form 12.922(c), Motion to Set Aside Florida Default or Default Judgment
(03/15)
- 220 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.923,
NOTICE OF HEARING (GENERAL) (03/15)

When should this form be used?

Anytime you have set a hearing before a judge, you must send notice of the hearing to the other party.

IMPORTANT: If your hearing has been set before a general magistrate, you should use Notice of Hearing
Before General Magistrate, Florida Family Law Rules of Procedure Form 12.920(c). If your hearing has
been set before a child support enforcement hearing officer, you should use Notice of Hearing (Child
Support Hearing Officer), Florida Supreme Court Approved Family Law Form 12.921.

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?

A copy of this form must be mailed, e-mailed, or hand delivered to the other party in your case. If a
default has been entered, you must still send this form to the other party to notify the other party of the
final hearing.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions for Florida Supreme Court Approved Family Law Form 12.923, Notice of Hearing (General)
(03/15)
- 221 -
Administration.

Where can I look for more information?

Before proceeding, you should read General Information for Self-Represented Litigants found at the
beginning of these forms. For further information on serving notices of hearing, see rule 1.090(d),
Florida Civil Rules of Procedure.

Special notes...
To set a hearing date and time, you will usually have to make a good-faith effort to coordinate a
mutually convenient date and time for you, the other parties in the case, and the judge, except in
certain emergency situations. Some circuits may have additional procedural requirements that you
must follow when you notify the court and other parties of your scheduled hearing. Therefore, before
you complete this form, you should contact the clerk’s office, family law intake staff, or judicial
assistant for information regarding the proper procedure to follow.

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.923, Notice of Hearing (General)
(03/15)
- 222 -
IN THE CIRCUIT COURT OF THE ____________________ JUDICIAL CIRCUIT,
IN AND FOR ____________________ COUNTY, FLORIDA

Case No.: __________________________
Division: ___________________________

______________________________________,
Petitioner,

and

_____________________________________,
Respondent.

NOTICE OF HEARING (GENERAL)

[fill in all blanks]
TO: {name of other party}: _______________________________________________________________
There will be a hearing before Judge {name} ________________________________________________,
on {date} ________________, at {time} _______m., in Room _____ of the ________________________
County Courthouse, on the following issues: _____________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________.
_____ hour(s)/_____ minutes have been reserved for this hearing.

This part is to be filled out by the court or to be filled in with information you obtained from the court:

Florida Supreme Court Approved Family Law Form 12.923, Notice of Hearing (General) (03/15)
- 223 -
If you are represented by an attorney or plan to retain an attorney for this matter, you should notify the
attorney of this hearing.

If this matter is resolved, the moving party shall contact the judge’s office to cancel this hearing.

I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-
delivered to the person(s) listed below on {date}_________________.

_____________________________________________
Signature of Party
Printed Name: _________________________________
Address: _____________________________________
City, State, Zip: ________________________________
Telephone Number: ____________________________
Fax Number: __________________________________
Designated E-mail Address(es):____________________
_____________________________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent
This form was completed with the assistance of:
{name of individual} __________________________________________________________________ ,
{name of business} ____________________________________________________________________ ,
{address} ____________________________________________________________________________ ,
{city} ________________, (state} ____, {zip code}__________,{telephone number} _________________ .

Florida Supreme Court Approved Family Law Form 12.923, Notice of Hearing (General) (03/15)
- 224 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED
FAMILY LAW FORM 12.924
NOTICE FOR TRIAL (03/15)

When should this form be used?

Generally, the court will have trials (or final hearings) in contested cases. This form is to be used to
notify the court that your case is ready to be set for trial. Before setting your case for trial, certain
requirements such as completing mandatory disclosure and filing certain papers and having them
served on the other party must be met. These requirements vary depending on the type of case and the
procedures in your particular circuit. In some circuits you must complete mediation or a parenting
course before you can set a final hearing by using a Notice of Hearing (General), Florida Supreme Court
Approved Family Law Form 12.923, or other appropriate notice of hearing form. Other circuits may
require that you set the trial using an Order Setting Trial. Contact the clerk of the circuit court, family
law intake staff, or judicial assistant to determine how the judge assigned to your case sets trials. For
further information, you should refer to the instructions for the type of form you are filing.

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?

A copy of this form must be mailed, e-mailed, or hand-delivered to the other party in your case.

Where can I look for more information?

Before proceeding, you should read General Information for Self-Represented Litigants found at the
beginning of these forms. For further information, see rule 12.440, Florida Family Law Rules of
Procedure.

Instructions for Florida Supreme Court Approved Family Law Form 12.924, Notice for Trial (03/15)
- 225 -
IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Special notes...

These family law forms contain orders and final judgments, which the judge may use. You should ask
the clerk of court, family law intake staff, or judicial assistant if you need to bring one of these forms
with you to the hearing or trial. If so, you should type or print the heading, including the circuit, county,
case number, division, and the parties’ names, and leave the rest blank for the judge to complete at
your hearing or trial.

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.924, Notice for Trial (03/15)
- 226 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
,
Petitioner,

and

_,
Respondent.

NOTICE FOR TRIAL

Pursuant to Rule 12.440, Florida Family Law Rules of Procedure, the party signing below states that the
case is ready to be set for trial. The estimated time needed for the parties to present their cases is:
{hours} .

I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-
delivered to the person(s) listed below on {date} .

Other party or his/her attorney:
Name:
Address:
City, State, Zip:
Fax Number:
Designated E-mail Address(es): ______________________

Signature of Party
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:

Designated E-mail Address(es):________________________________________________________

Florida Supreme Court Approved Family Law Form 12.924, Notice for Trial (03/15)
- 227 -
IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent
This form was completed with the assistance of:
{name of individual} ____________________________________________________________________ ,
{name of business} _____________________________________________________________________ ,
{address}
______________________________________________,
{city} ___________________,{state} _____,{zip code}________, {telephone number} .

Florida Supreme Court Approved Family Law Form 12.924, Notice for Trial (03/15)
- 228 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.927,
NOTICE OF VOLUNTARY DISMISSAL
(03/15)
When should this form be used?

If you are the petitioner in a case and you wish to discontinue (dismiss) the case, you may use this form
to request that the court dismiss your petition. If you are the respondent in a case and you have filed a
counterpetition, you may use this form to request that the court dismiss your counterpetition.

WARNING: If your case involves both a petition and a counterpetition, a notice of voluntary dismissal
filed by one party will NOT dismiss the other party’s petition or counterpetition. The other party also
must file a notice of voluntary dismissal for the entire case to stop completely.

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?

A copy of this form must be mailed, e-mailed or hand-delivered to each party in the case.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

SELF-REPRESENTED LITIGANTS MAY SERVE DOCUMENTS BY E-MAIL; HOWEVER, THEY ARE NOT

Instructions for Florida Supreme Court Approved Family Law Form 12.927, Notice of Voluntary Dismissal (03/15)
- 229 -
REQUIRED TO DO SO. If a self-represented litigant elects to serve and receive documents by e-mail, the
procedures must always be followed once the initial election is made.

Where can I look for more information?

Before proceeding, you should read General Information for Self-Represented Litigants found at the
beginning of these forms. For further information, see 12.420, Florida Family Law Rule of Procedure
12.420.

Special notes...

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.927, Notice of Voluntary Dismissal (03/15)
- 230 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
__________________________________ ,
Petitioner,

and

____________________________________,
Respondent.

NOTICE OF VOLUNTARY DISMISSAL

I, {full legal name} , give notice that:
[choose one only]

a. _____ I am the Petitioner in this case and I voluntarily dismiss my petition.
b. _____ I am the Respondent in this case and I voluntarily dismiss my counterpetition.

I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand
delivered to the person(s) listed below on {date} .

Other party or his/her attorney:
Name:
Address:
City, State, Zip:
Fax Number:
Designated E-mail Address(es):_____________________

Signature of Party
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail

Florida Supreme Court Approved Family Law Form 12.927, Notice of Voluntary Dismissal (03/15)
- 231 -
Address(es):_________________________________________________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent.
This form was completed with the assistance of:
{name of individual} _____________________________________________________________ ,
{name of business} _______________________________________________________________ ,
{address} _______________________________________________________________________ ,
{city} ________________, {state}______, {zip code}________,{telephone number} _____ .

Florida Supreme Court Approved Family Law Form 12.927, Notice of Voluntary Dismissal (03/15)
- 232 -
INSTRUCTIONS FOR SUPREME COURT APPROVED FAMILY LAW FORMS
12.931(a), NOTICE OF PRODUCTION FROM NONPARTY AND 12.931(b),
SUBPOENA FOR PRODUCTION OF DOCUMENTS FROM NONPARTY
(03/15)

When should these forms be used?

These forms should be used if you need copies of documents (for a purpose relating to your case) from a
nonparty in your case. Both forms should be typed or printed in black ink.

Notice of Production from Nonparty, Florida Supreme Court Approved Family Law Form 12.931(a), is
used to notify the other party in your case that in 10 days you are going to subpoena documents from a
nonparty. Subpoena for Production of Documents from Nonparty, Florida Supreme Court Approved
Family Law Form 12.931(b), is the actual subpoena directing the nonparty to produce specific
documents. You must file the originals of these forms with the clerk of the circuit court. A copy of these
forms must be mailed, e-mailed, or hand delivered to any other party in your case.

IMPORTANT INFORMATION REGARDING E-FILING

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

To serve and receive documents by e-mail, you must designate your e-mail addresses by using the
Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family Law Form
Instructions for Florida Supreme Court Approved Family Law Forms 12.931(a) Notice of Production from Nonparty
and 12.931(b) Subpoena for Production of Documents from Nonparty (03/15)
- 233 -
12.915, and you must provide your e-mail address on each form on which your signature appears.
Please CAREFULLY read the rules and instructions for: Certificate of Service (General), Florida Supreme
Court Approved Family Law Form 12.914; Designation of Current Mailing and E-mail Address, Florida
Supreme Court Approved Family Law Form 12.915; and Florida Rule of Judicial Administration 2.516.

What should I do next?
Ten days after you serve the Notice of Production from Nonparty, Florida Supreme Court Approved
Family Law Form 12.931(a), on the other party in your case (15 days if service is by mail or e-mail), you
should ask the clerk of the court to sign the subpoena. You should contact the deputy sheriff or private
process server and have the subpoena personally served on the person named in the subpoena.

Where can I look for more information?

Before proceeding, you should read General Information for Self-Represented Litigants found at the
beginning of these forms. Because these papers must also comply with rule 12.280, Florida Family Law
Rule of Procedure, and rules 1.280, 1.350, 1.351, and 1.410, Florida Rules of Civil Procedure, you also
should read those rules.

Special Notes

If the other party in your case objects in writing within 10 days (allow an additional 5 days if served by
mail or e-mail) of service of the Notice of Production from Nonparty, Florida Supreme Court Approved
Family Law Form 12.931(a), you may not use this procedure to obtain documents from the nonparty
unless and until the court orders otherwise.

The nonparty receiving the subpoena may charge you a reasonable fee for copies of the documents.

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Forms 12.931(a) Notice of Production from Nonparty
and 12.931(b) Subpoena for Production of Documents from Nonparty (03/15)
- 234 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
,
Petitioner,

and

,
Respondent.

NOTICE OF PRODUCTION FROM NONPARTY
TO:
{all parties}

YOU ARE NOTIFIED that, after 10 days from the date of service of this notice, the undersigned will apply
to the clerk of this Court for issuance of the attached subpoena directed to {name of person,
organization, or agency} , who is not a party, to produce
the items listed at the time and place specified in the subpoena. Objections to the issuance of this
subpoena must be filed with the clerk of the circuit court within 10 days.

I certify that a copy of this document was ( ) mailed ( ) faxed and mailed
( ) e-mailed ( ) hand-delivered to the person(s) listed below on
{date}__________________________.

Other party or his/her attorney (if represented) Other

________________________________________ ________________________________________
Printed Name Printed Name
________________________________________ ________________________________________
Address Address
________________________________________ ________________________________________
City, State, Zip City, State, Zip
________________________________________ ________________________________________
Telephone (area code and number) Telephone (area code and number)
________________________________________ ________________________________________
Fax (area code and number) Fax (area code and number)
_________________________________________
_______________________________________
Designated E-mail Address(es) Designated E-mail Address(es)

Florida Supreme Court Approved Family Law Form 12.931(a) Notice of Production from Nonparty (03/15)
- 235 -
___________________________________________
Signature of Party
Printed Name: ______________________________
Address: ___________________________________
City, State, Zip: ______________________________
Telephone Number: __________________________
Fax Number: ________________________________
Designated E-mail Address(es):_________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent
This form was completed with the assistance of:
{name of individual},______________________________________________________________ ,
{name of business} __________________________________________________________________ ,
{address} ___________________________________________________________________________
,
{city} __________, {state}________,{zip code}___________, {telephone number} _________________
.

Florida Supreme Court Approved Family Law Form 12.931(a) Notice of Production from Nonparty (03/15)
- 236 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:________________________________
Division: ____________________________

,
Petitioner,

and

,
Respondent.

SUBPOENA FOR PRODUCTION OF DOCUMENTS FROM NONPARTY

THE STATE OF FLORIDA
TO: ________________________________________________________________________________

YOU MUST go to {place}_______________________________________________________, on
{date} ________________, at {time} ________, a.m./p.m. and bring with you at that time and place the
following:_____________________________________________________________________________
_____________________________________________________________________________________
_
_____________________________________________________________________________________
_
_____________________________________________________________________________________
_
_____________________________________________________________________________________
_
These items will be inspected and may be copied at that time. You will not have to leave the original
items.

You may obey this subpoena by providing readable copies of the items to be produced to the party or
his/her attorney whose name appears on this subpoena on or before the scheduled date of production.
You may condition the preparation of the copies upon payment in advance of the reasonable cost of
preparation. If you mail or deliver the copies to the attorney whose name appears on this subpoena
before the date indicated above, you do not have to appear in person.

You may be in contempt of court if you fail to: (1) appear as specified; (2) furnish the records instead
Florida Supreme Court Approved Family Law Form 12.931(b), Subpoena for Production from a Nonparty
(03/15)
- 237 -
of appearing as provided above; or (3) object to this subpoena.

You can only be excused by the person whose name appears on this subpoena and, unless excused by
that person of the Court, you shall respond as directed.

This part to be filled out by the court or filled in with information obtained from the court:

If you are a person with a disability who needs any accommodation in order
to participate in this proceeding, you are entitled, at no cost to you, to the
provision of certain assistance. Please contact:________________________
__________________________________________________________________
{identify applicable court personnel by name, address, and telephone number}
at least 7 days before your scheduled court appearance, or immediately upon
receiving this notification if the time before the scheduled appearance is less
than 7 days; if you are hearing or voice impaired, call 711.
Dated:_______________________

CLERK OF THE CIRCUIT COURT (SEAL)

By:_______________________________________
Deputy Clerk

I CERTIFY that I gave notice to every other party to this action of my intent to serve a subpoena upon a
person who is not a party to this action directing that person to produce documents or things without
deposition. I also certify that no objection under Florida Rule of Civil Procedure 1.351 has been received
by the undersigned within 10 days of service of this notice, if service was by hand-delivery or
appropriate facsimile transmission, and within 15 days if service was by mail or e-mail.

Dated: ___________________________
______________________________________________
Signature of Party
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es): ____________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent
Florida Supreme Court Approved Family Law Form 12.931(b), Subpoena for Production from a Nonparty
(03/15)
- 238 -
This form was completed with the assistance of:
{name of individual } _____________________________________ ,
{name of business}______________________________________________________________________,
{address} _____________________________________________________ ,
{city}_________________,{state}____, {zip code}___________, {telephone number}_________________.

Florida Supreme Court Approved Family Law Form 12.931(b), Subpoena for Production from a Nonparty
(03/15)
- 239 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY
LAW FORM 12.940(d),
MOTION TO MODIFY OR DISSOLVE TEMPORARY INJUNCTION (03/15)

When should this form be used?

If a temporary injunction, either ex parte or after a hearing, has been entered against you, you may
use this form to ask the court to modify or dissolve that injunction. This motion should not be used
to dissolve a Temporary Injunction for Protection Against Domestic Violence.

This form should be typed or printed in black ink. After completing this form, you should file the
original with the clerk of the circuit court in the county where the injunction was entered and keep
a copy for your records. You should ask the clerk to process your motion through their emergency
procedures. A hearing will be held within 5 working days. You should ask for the date and time of
your hearing and should file Notice of Hearing (General), Florida Supreme Court Approved Family
Law Form 12.923 or other appropriate notice of hearing form, and send a copy to the other party.

IMPORTANT INFORMATION REGARDING E-FILING

The Florida Rules of Judicial Administration now require that all petitions, pleadings, and documents
be filed electronically except in certain circumstances. Self-represented litigants may file petitions
or other pleadings or documents electronically; however, they are not required to do so. If you
choose to file your pleadings or other documents electronically, you must do so in accordance with
Florida Rule of Judicial Administration 2.525, and you must follow the procedures of the judicial
circuit in which you file. The rules and procedures should be carefully read and followed.

What should I do next?

A copy of this form must be mailed, e-mailed, or hand delivered to the other party, along with a
notice of hearing.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions for Florida Supreme Court Approved Family Law Form 12.940(d), Motion to Modify or Dissolve
Temporary Injunction (03/15)
- 240 -
Rules of Judicial Administration.

To serve and receive documents by e-mail, you must designate your e-mail addresses by using the
Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family Law
Form 12.915, and you must provide your e-mail address on each form on which your signature
appears. Please CAREFULLY read the rules and instructions for: Certificate of Service (General),
Florida Supreme Court Approved Family Law Form 12.914; Designation of Current Mailing and E-
mail Address, Florida Supreme Court Approved Family Law Form 12.915; and Florida Rule of Judicial
Administration 2.516.

Where can I look for more information?

Before proceeding, you should read “General Information for Self-Represented Litigants” found at
the beginning of these forms. For further information, see chapter 61, Florida Statutes, and rule
1.610, Florida Rules of Civil Procedure.
Special notes...

If parental responsibility or time-sharing of a minor child(ren) is at issue, you must also file the
following, if you have not already done so:

 Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida
Supreme Court Approved Family Law Form 12.902(d).

Order... These family law forms contain an Order Dissolving Temporary Injunction, Florida Supreme
Court Approved Family Law Form 12.940(e), which the judge may use. You should check with the
clerk, family law intake staff, or judicial assistant to see if you need to bring a blank order form with
you to the hearing. If so, you should type or print the heading, including the circuit, county, case
number, division, and the parties’ names, and leave the rest blank for the judge to complete at your
hearing or trial.

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of Disclosure from Nonlawyer, Florida Family Law
Rules of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill out
these forms also must put his or her name, address, and telephone number on the bottom of the
last page of every form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.940(d), Motion to Modify or Dissolve
Temporary Injunction (03/15)
- 241 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
,
Petitioner,
and

,
Respondent.

MOTION TO MODIFY OR DISSOLVE TEMPORARY INJUNCTION

_____ Petitioner _____ Respondent requests the Court to enter an order _____ dissolving the
temporary injunction issued in the above styled case _____ modifying the temporary injunction issued
in the above styled case in the following manner:

I am the party against whom this temporary injunction has been granted and under rule 1.610, Florida
Rules of Civil Procedure, I request that a hearing be held within 5 days after the filing of this motion.

I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed
( ) hand delivered to the person(s) listed below on {date} .

Other party or his/her attorney:
Name:
Address:
City, State, Zip:
Fax Number:
Designated E-mail Address(es):__________________
__________________________________________

Signature of Party
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es):__________________
___________________________________________

Florida Supreme Court Approved Family Law Form 12.940(d), Motion to Modify or Dissolve Temporary Injunction
(03/15)
- 242 -
IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent
This form was completed with the assistance of:
{name of individual} ______________________________________________________________ ,
{name of business}________________________________________________________________ ,
{address} __________________________________________ ,
{city} _____________,{state} ____, {zip code}_______,{telephone number} _____________________.

Florida Supreme Court Approved Family Law Form 12.940(d), Motion to Modify or Dissolve Temporary Injunction
(03/15)
- 243 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
,
Petitioner,
and

,
Respondent.

ORDER DISSOLVING TEMPORARY INJUNCTION

Upon _____Petitioner’s _____ Respondent’s motion and after hearing, the Court, being fully advised in
the premises,

ORDERS that the temporary injunction entered on {date} in the
above-styled case is hereby dissolved.

DONE AND ORDERED in ________________________, Florida, on {date} _.

CIRCUIT JUDGE

I certify that a copy of {name of document} __________________________________was ( ) mailed
( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the parties and any other person(s) or entities
listed below on {date} ________________:

__________________________________________
By Clerk of Court, Designee, or Judicial Assistant

Petitioner (or his or her attorney)
Respondent (or his or her attorney)

U.S. Department of State
Office of Children’s Issues
2201 “C” Street NW
CA/OCS/CI
Washington, D.C. 20520
Fax (202) 736-9133
preventabduction@state.gov

Florida Supreme Court Approved Family Law Form 12.940(e), Order Dissolving Temporary Injunction (03/15)
- 244 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY
LAW FORM 12.941(a),
VERIFIED MOTION FOR TEMPORARY INJUNCTION TO PREVENT
REMOVAL OF MINOR CHILD(REN) AND/OR DENIAL OF PASSPORT
SERVICES (03/15)

When should this form be used?

You should use this form if you want the court to enter an order that your minor child(ren) is (are)
not to be removed from the State of Florida while a case involving parenting or time-sharing is
pending, that passport services for the minor child(ren) be prohibited, and/or that existing passports
be turned over to you.

This form should be typed or printed in black ink. If you want the court to enter an ex parte order,
without giving the other side advance notice of the hearing, you should explain your reasons in
paragraph 5 of this form. After completing this form, you should sign the form before a notary
public. You should file the original with the clerk of the circuit court in the county where your case
is pending and keep a copy for your records. You should also ask the clerk to process your motion
though their emergency procedures.

IMPORTANT INFORMATION REGARDING E-FILING

The Florida Rules of Judicial Administration now require that all petitions, pleadings, and documents
be filed electronically except in certain circumstances. Self-represented litigants may file petitions
or other pleadings or documents electronically; however, they are not required to do so. If you
choose to file your pleadings or other documents electronically, you must do so in accordance with
Florida Rule of Judicial Administration 2.525, and you must follow the procedures of the judicial
circuit in which you file. The rules and procedures should be carefully read and followed.

What should I do next?

Instructions for Florida Supreme Court Approved Family Law Form 12.941(a), Verified Motion for Temporary
Injunction to Prevent Removal of Minor Child(ren) and/or Denial of Passport Services (03/15)
- 245 -
If the court will not enter an order without advance notice to the other side, you should check with
the clerk of court, family law intake staff, or judicial assistant for information on the local
procedure for scheduling a hearing on your motion, unless the court sets a hearing in its order
denying your request for an ex parte hearing. When you know the date and time of your hearing,
you should file Notice of Hearing (General), Florida Supreme Court Approved Family Law Form
12.923 or other appropriate notice of hearing form, and use personal service to notify the other
party of your motion, the court’s order, if any, and the hearing.

Where can I look for more information?

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

To serve and receive documents by e-mail, you must designate your e-mail addresses by using the
Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family Law
Form 12.915, and you must provide your e-mail address on each form on which your signature
appears. Please CAREFULLY read the rules and instructions for: Certificate of Service (General),
Florida Supreme Court Approved Family Law Form 12.914; Designation of Current Mailing and E-
mail Address, Florida Supreme Court Approved Family Law Form 12.915; and Florida Rule of Judicial
Administration 2.516.

Special notes...

Instructions for Florida Supreme Court Approved Family Law Form 12.941(a), Verified Motion for Temporary
Injunction to Prevent Removal of Minor Child(ren) and/or Denial of Passport Services (03/15)
- 246 -
If you have an attorney, your attorney must certify in writing the efforts that have been made to
give the other party notice, if no notice is given. The court may require you to post a bond as a
condition of the injunction.

With this form you must also file the following, if you have not already done so, and provide a copy
to the other party:

 Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida
Supreme Court Approved Family Law Form 12.902(d).

Temporary Injunctions... These family law forms contain a Temporary Injunction to Prevent
Removal of Minor Child(ren) and/or Denial of Passport Services (Ex Parte), Florida Supreme Court
Approved Family Law Form 12.941(b), which the judge may use if he or she enters an order without
a hearing, and a Temporary Injunction to Prevent Removal of Minor Child(ren) and/or Denial of
Passport Services (After Notice), Florida Supreme Court Approved Family Law Form 12.941(c),
which the judge may use if he or she enters an order after a hearing. You should check with the
clerk, family law intake staff, or judicial assistant to see if you need to bring a blank order form with
you to the hearing. If so, you should type or print the heading, including the circuit, county, case
number, division, and the parties’ names, and leave the rest blank for the judge to complete at your
hearing.

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of Disclosure from Nonlawyer, Florida Family Law
Rules of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out
these forms also must put his or her name, address, and telephone number on the bottom of the
last page of every form he or she helps you complete.

Case No.:
Division:
,
Petitioner,

and

,
Respondent.

VERIFIED MOTION FOR TEMPORARY INJUNCTION TO PREVENT
REMOVAL OF MINOR CHILD(REN) AND/OR DENIAL OF PASSPORT
SERVICES

_____ Petitioner _____ Respondent requests the Court to enter a temporary injunction to prevent
removal of the following listed minor child(ren) from the jurisdiction of this Court and deny passport
services for the child(ren) and says:

1. The minor child(ren) subject to this request is (are):
Name Birth date

2. The child(ren) has (have) been a resident(s) of __________ County, Florida since
{date} ______________.

3. A completed Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida
Supreme Court Approved Family Law Form 12.902(d), _____is filed with this motion or _____
has already been filed.

4. It is in the best interests of the minor child(ren) that the Court order the following:
{Indicate all that apply}
a. _____The child(ren) not be removed from the jurisdiction of this Court while litigation is
pending because:________________________________________________________________

Florida Supreme Court Approved Family Law Form 12.941(a), Verified Motion for Temporary Injunction to Prevent
Removal of Minor Child(ren) and/or Denial of Passport Services (03/15)
- 248 -
_____________________________________________________________________________
b. _____Passport services for the minor child(ren) be prohibited because:____________________
_____________________________________________________________________________
_____________________________________________________________________________
c. ____Existing passports for the minor child(ren) be immediately turned over to
_____Petitioner _____ Respondent because: _____________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

5. This motion should be granted _____ with _____ without notice to the other party. {If without
notice, explain why there would be immediate and irreparable harm if the other party is given
notice.}
__________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________ .

WHEREFORE, _____ Petitioner _____ Respondent requests the following from the Court:
{Indicate all that apply}
a. ____enter a temporary injunction to prevent removal of the child(ren) named above from the
jurisdiction of this Court while this action is pending;
b. ____enter an order denying passport services for the minor child(ren);
c. ____enter an order requiring that any existing passports for the minor child(ren) be immediately
delivered to _____ Petitioner _____ Respondent;
d. ____enter a temporary injunction without notice to the other party.

I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand
delivered to the person(s) listed below on {date} _______________________________ or ( ) was not
delivered to the person(s) listed below because ________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
.

Other party or his/her attorney:
Name:
Address:

Florida Supreme Court Approved Family Law Form 12.941(a), Verified Motion for Temporary Injunction to Prevent
Removal of Minor Child(ren) and/or Denial of Passport Services (03/15)
- 249 -
City, State, Zip:
Fax Number:
Designated E-mail Address(es):____________________
_____________________________________________
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
verified motion and that the punishment for knowingly making a false statement includes fines
and/or imprisonment.

Dated:
Signature of Party
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es):_______________
_______________________________________

STATE OF FLORIDA
COUNTY OF ______________________

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

[Print, type, or stamp commissioned name of notary or clerk.]
__ Personally known
__ Produced identification
Type of identification produced ______________________________

I, the undersigned attorney for the movant, hereby certify in that the following efforts have been made
to give notice. {if no efforts have been made, why}

Signature
Printed Name:_____________
Florida Bar Number:_____________
Address:________________________________
City, State, Zip:___________________________
Telephone Number:_______________________
Fax Number:_____________________________
Designated E-mail Address(es):_______________
______________________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent
This form was completed with the assistance of:
{name of individual} ______________________________________________________________ ,
{name of business}___________________________________________________________________
,
{address}__________________________________________________________________________ ,
{city} _____________,{state} _____, {zip code}_________,{telephone number} __________________.

Florida Supreme Court Approved Family Law Form 12.941(a), Verified Motion for Temporary Injunction to Prevent
Removal of Minor Child(ren) and/or Denial of Passport Services (03/15)
- 251 -
IN THE CIRCUIT COURT OF THE _____________________ JUDICIAL CIRCUIT,
IN AND FOR ______________________________ COUNTY, FLORIDA

Case No: ________________________
Division: ________________________

_________________________________,
Petitioner,
and

_________________________________,
Respondent.

TEMPORARY INJUNCTION TO PREVENT REMOVAL OF MINOR
CHILD(REN) AND/OR DENIAL OF PASSPORT SERVICES
(EX PARTE)
Upon verified motion of _____ Petitioner _____Respondent, the Court has jurisdiction of the parties and
the subject matter and the Court being fully advised, it is ORDERED and ADJUDGED that:

NOTICE OF HEARING
This Temporary Injunction to Prevent Removal of Child(ren) has been issued without prior notice to
Respondent. Pursuant to Rule 1.610, Florida Rules of Civil Procedure, the other party may file a motion
to dissolve or modify this temporary injunction and a hearing will be scheduled within 5 days of that
motion.

If no motion to dissolve is filed, Petitioner and Respondent are instructed that they are scheduled to
appear and testify at a hearing regarding this matter on {date}__________________, at _____
a.m./p.m., when the Court will consider whether the Court should continue, modify, or dissolve this
Temporary Injunction to Prevent Removal of Child(ren) and/or Denial of Passport Services, which
would remain in effect until modified or dissolved by the Court, and whether other things should be
ordered, including who should pay the filing fees and costs. The hearing will be before The Honorable
{name} _____________________________________________, at {room name/number, location,
address, city}
_____________________________________________________________________________, Florida.

IF PETITIONER AND/OR RESPONDENT DO (DOES) NOT APPEAR, THIS TEMPORARY INJUNCTION MAY
BE CONTINUED IN FORCE, EXTENDED, OR DISMISSED, AND/OR OTHER ADDITIONAL ORDERS MAY BE
ISSUED, INCLUDING THE IMPOSITION OF COURT COSTS.

Florida Supreme Court Approved Family Law Form 12.941(b), Temporary Injunction to Prevent Removal of Minor
Child(ren) and/or Denial of Passport Services (Ex Parte) (03/15)
- 252 -
If you are a person with a disability who needs any accommodation in order
to participate in this proceeding, you are entitled, at no cost to you, to the
provision of certain assistance. Please contact:

__________________________________________________________________
{identify applicable court personnel by name, address, and telephone number}
at least 7 days before your scheduled court appearance, or immediately upon
receiving this notification if the time before the scheduled appearance is less
than 7 days; if you are hearing or voice impaired, call 711.
FINDINGS
1. It appears from specific facts shown by verified motion that immediate and irreparable injury, loss,
or damage will result to the minor child(ren) if a temporary injunction is not issued without notice to
the other party.

2. _____ Petitioner’s _____ Respondent’s attorney has certified in writing any efforts made to give
notice.

3. The reasons why notice should not be given are: __________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

TEMPORARY INJUNCTION
{Indicate all that apply}
1. _____The following child(ren) shall not be removed from the jurisdiction of this Court during the
pendency of this proceeding, or until further order of this Court:

Name Birth date
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

2. _____ Petitioner _____Respondent shall not apply for any passports or passport services on behalf
of the child(ren).

Florida Supreme Court Approved Family Law Form 12.941(b), Temporary Injunction to Prevent Removal of Minor
Child(ren) and/or Denial of Passport Services (Ex Parte) (03/15)
- 253 -
3. _____ Petitioner _____ Respondent shall immediately deliver any existing passports for the
child(ren) to {name} ____________________________________________________.

4. The Court may enforce compliance with the terms of this injunction through civil and/or indirect
criminal contempt proceedings, which may include arrest, incarceration, and/or the imposition of a
fine.

5. Violation of this injunction may constitute criminal contempt of court.

6. Bond.
a. _____ Bond is waived because this injunction is issued solely to prevent physical injury or abuse
of a natural person.

b. _____ This order is conditioned upon _____ Petitioner _____ Respondent posting bond in the
sum of $ _________ with the clerk of this Court.

EXPIRATION.
This injunction shall remain in effect until the minor child(ren) reach(es) the age of 18, until the hearing
scheduled herein, if any, or {date}_______________________, whichever occurs first, unless modified
by further order of this Court.

DONE AND ORDERED at _________________________, Florida on {date} _________________ .

__________________________________________
CIRCUIT JUDGE

I certify that a copy of the {name of document(s)} ________________________________________ was
( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the parties and any other
person(s) or entities listed below on {date}____________________________.

________________________________________
By: Clerk of Court, Designee, or Judicial Assistant
Petitioner (or his or her attorney)
Respondent (or his or her attorney)

U.S. Department of State
Office of Children’s Issues
2201 “C” Street NW
CA/OCS/CI

Case No.:
Division:
,
Petitioner,

and

,
Respondent.

TEMPORARY INJUNCTION TO PREVENT REMOVAL OF MINOR
CHILD(REN) AND/OR DENIAL OF PASSPORT SERVICES
(AFTER NOTICE)
Upon verified motion of _____Petitioner _____ Respondent, the Court has jurisdiction of the parties and
the subject matter and the Court being fully advised, it is ORDERED and ADJUDGED that:

{Indicate all that apply}
1. The following minor child(ren) shall not be removed from the jurisdiction of this Court during the
pendency of this proceeding, or until further order of this Court:

Name Birth date
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

2. _____ Petitioner _____Respondent shall not apply for any passports or passport services on behalf
of the child(ren).

3. _____ Petitioner _____Respondent shall immediately deliver any existing passports for the
child(ren) to {name} _____________________________________________________________.

5. Violation of this injunction may constitute criminal contempt of court.

Florida Supreme Court Approved Family Law Form 12.941(c), Temporary Injunction to Prevent Removal of Minor
Child(ren) and/or Denial of Passport Services (After Notice) (03/15)
- 256 -
6. Bond.
a. _____Bond is waived because this injunction is issued solely to prevent physical injury or abuse
of a natural person.
b. _____This order is conditioned upon _____Petitioner _____Respondent posting bond in the
sum of $ _______ with the clerk of this Court.

7. Expiration.
This temporary injunction shall remain in effect until the minor child(ren) reach(es) the age of 18, or
until {date} ____________________, not to exceed one year from the date of this order, whichever
occurs first, unless modified by further order of this Court.

DONE AND ORDERED at ______________________, Florida, on {date}_____________________.

____________________________________________
CIRCUIT JUDGE

I certify that a copy of the {name of document(s)} ___________________________________________
was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the parties and any other
person(s) or entities listed below on {date}_____________________.

_______________________________________
By: Clerk of Court, Designee, or Judicial Assistant

Petitioner (or his or her attorney)
Respondent (or his or her attorney)

U.S. Department of State
Office of Children’s Issues
2201 “C” Street NW
CA/OCS/CI
Washington, D.C. 20520
Fax (202) 736-9133
preventabduction@state.gov

Florida Supreme Court Approved Family Law Form 12.941(c), Temporary Injunction to Prevent Removal of Minor
Child(ren) and/or Denial of Passport Services (After Notice) (03/15)
- 257 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.941(d)
EMERGENCY VERIFIED MOTION FOR CHILD PICK-UP ORDER
(03/15)
When should this form be used?

You may use this form to request that the court enter an order directing the sheriff or other law
enforcement officer to take a minor child(ren) from the person who currently has physical possession of
the child(ren) and deliver the child(ren) to your physical custody or possession. This form should only be
used in an emergency by a person who has a pre-existing legal right to physical possession of a minor
child. This means that you already have a court order awarding you legal custody of or time-sharing
with the child(ren) OR you are the birth mother of one or more children born out of wedlock and no
court order has addressed any other person’s parental rights. Before proceeding, you should read
General Information for Self-Represented Litigants found at the beginning of these forms.

This form should be typed or printed in black ink. This form presumes that you want the court to enter
an ex parte order without giving the other side advance notice of the hearing. You should explain your
reasons for why such an ex parte order should be entered in paragraph 7 of this form. After completing
this form, you should sign the form before a notary public or deputy clerk. You should file the original,
along with all of the other forms required, with the clerk of the circuit court in the county where the
child(ren) is (are) physically located and keep a copy for your records. You should also ask the clerk to
process your motion though their emergency procedures.

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?

If the court enters an order without advance notice to the other party, you should take a certified copy
of the order to the sheriff’s office for further assistance. You must have this form and the court’s order
served by personal service on the other party. You should read the court’s order carefully. The order
may require the sheriff to place the child(ren) somewhere other than in your physical possession. Look
for directions in the order that apply to you and note the time and place of the hearing scheduled in the
order. You should go to the hearing with whatever evidence you have regarding your motion.
Instructions for Florida Supreme Court Approved Family Law Form 12.941(d), Emergency Verified Motion for Child
Pick-Up Order (03/15)
- 258 -
If the court will not enter an order without advance notice to the other side, you should check with the
clerk of court, judicial assistant, or family law intake staff for information on the local procedure for
scheduling a hearing on your motion, unless the court sets a hearing in its order denying your request
for an ex parte hearing. When you know the date and time of your hearing, you should file Notice of
Hearing (General), Florida Supreme Court Approved Family Law Form 12.923, and use personal service
to notify the other party of your motion, the court’s order, if any, and the hearing.

Special notes...

With this form you must also file the following:

 Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida Supreme
Court Approved Family Law Form 12.902(d).

 A certified copy of the court order showing that you have legal custody of or time-sharing with
the child(ren), if any.

 A certified copy of the child(ren)’s birth certificate(s), if you are the birth mother of a
child born out of wedlock and no court order addressing paternity exists.
OR
 A certified copy of any judgment establishing paternity, time-sharing with or custody of
the minor child(ren).

Order... These family law forms contain an Order to Pick-Up Minor Child(ren), Florida Supreme Court
Approved Family Law Form 12.941(e), which the judge may use. You should check with the clerk, family
law intake staff, or judicial assistant to see if you need to bring a blank order form with you to the
hearing. If so, you should type or print the heading, including the circuit, county, case number, division,
and the parties’ names, and leave the rest blank for the judge to complete at your hearing.

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.941(d), Emergency Verified Motion for Child
Pick-Up Order (03/15)
- 259 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
,
Petitioner,

and

,
Respondent.

EMERGENCY VERIFIED MOTION FOR CHILD PICK-UP ORDER

I, {full legal name} , being sworn,
certify that the following information is true:

1. This is a motion to enforce existing custody or time -sharing rights (as an operation of law or
court-ordered) regarding the following minor child(ren):

Name Sex Birth Date Race Physical Description

2. Currently, the child(ren) subject to this motion is (are) in the physical possession of
{full legal name}
whose address or present physical location is: ____________________________________

This individual’s relationship to the minor child(ren) is:

3. I _____ am _____ am not married to the person named in paragraph 2.

4. Status of minor child(ren). I have a superior right to custody of or time-sharing with the minor
child(ren) over the person named in paragraph 2 because:
{Indicate all that apply}:

Florida Supreme Court Approved Family Law Form 12.941(d), Emergency Verified Motion for Child Pick-Up Order
(03/15)
- 260 -
a. _____ Custody or Time-Sharing has been established by a court.
A final judgment or order awarding custody of or time-sharing with the minor child(ren) was made on
{date} _____________in {name of court} ________________________________
{case number} _____. This order awarded custody of or specific time-sharing with the
minor child(ren) to me. This final judgment or order applies to the following minor child(ren): {list
name(s) of the child(ren) or write all}
_____________________________________________________________________
_____________________________________________________________________
A certified copy of said final judgment or order is attached, has not been modified, and is still in effect.
{Indicate if applicable} _____ This order is an out-of-state court order which is entitled to full faith and
credit enforcement under the Uniform Child Custody Jurisdiction and Enforcement Act and/or the
federal Parental Kidnaping Prevention Act.

b. _____ Custody or time-sharing is established as an operation of law. I am the birth mother
of the minor child(ren) who was (were) born out of wedlock and there is no final judgment
or order awarding custody of or time-sharing with the following minor child(ren): {list
name(s) of the child(ren) or write all} __________________________________________
_________________________________________________________________________
_________________________________________________________________________
1. ____ Paternity has NOT been established. A certified copy of the minor child(ren)’s
birth certificate is attached and has not been amended.
2. ____ Paternity has been established. A certified copy of the final judgment of
paternity, which shows no award of custody or time-sharing was made, is attached. This
order has not been changed and is still in effect.

c. _____ Other: _____

5. A completed Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida
Supreme Court Approved Family Law Form 12.902(d), is filed with this motion.

6. Facts relating to the minor child(ren)’s current situation.
[Indicate all that apply]
a. _____The person named in paragraph 2 wrongfully removed or wrongfully detained the
minor child(ren) on {date} as follows: ____________________________

_______ Please indicate here if you are attaching additional pages to continue these facts.

b. _____ I believe that the minor child(ren) is (are) in immediate danger of harm or removal

Florida Supreme Court Approved Family Law Form 12.941(d), Emergency Verified Motion for Child Pick-Up Order
(03/15)
- 261 -
from this court’s jurisdiction while with the person named in paragraph 2 based on the
following: ___________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________ .

c. _____ The current location of the minor child(ren) is: {choose only one} ( ) unknown
( ) believed to be at the following address(es) with the following people
{list both the address and the people you believe will be there}:

7. Advance notice of this motion to the individual named in paragraph 2 should not be required
because:
______________________________________________________________________

8. If needed, I can be contacted for notice of an emergency or expedited hearing at the following
addresses/locations:
____________________________________________________________
Name of Contact Person:
_________________________________________________________
Address:
______________________________________________________________________
Telephone number(s) where I (or my designee) can be reached: {give name of individual to
call} ______________________________________________________________________________
Name of Contact Person:
Address:
Telephone number(s) where I (or my designee) can be reached: {give name of individual to
call} ______________________________________________________________________________

9. Attorneys’ Fees, Costs, and Suit Monies.
[Indicate if applicable]
______I have filed this motion because of wrongful acts of the person listed in paragraph 2
above. I request that this Court award reasonable attorney’s fees, costs, and suit monies as applicable
or authorized under Florida law, the UCCJEA, and other legal authorities.

WHEREFORE, I request an Emergency Order to Pick-Up Minor Child(ren), without advance notice,
directing all sheriffs of the State of Florida or other authorized law enforcement officers in this state or

Florida Supreme Court Approved Family Law Form 12.941(d), Emergency Verified Motion for Child Pick-Up Order
(03/15)
- 262 -
any other state to pick up the previously named minor child(ren) and deliver them to my physical
custody.

Florida Supreme Court Approved Family Law Form 12.941(d), Emergency Verified Motion for Child Pick-Up Order
(03/15)
- 263 -
I understand that I am swearing or affirming under oath to the truthfulness of the claims made above
and that the punishment for knowingly making a false statement includes fines and/or imprisonment.

Dated: _____________________
__________________________________________
Signature of Party
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es):____________________
_____________________________________________

STATE OF FLORIDA
COUNTY OF ________________________
Sworn to or affirmed and signed before me on by

NOTARY PUBLIC or DEPUTY CLERK

[Print, type, or stamp commissioned name of notary or clerk.]
____ Personally known
____ Produced identification
Type of identification produced _______________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent
This form was completed with the assistance of:
{name of individual}________________________________________________________________ ,
{name of business} __________________________________________________________________ ,
{address} _________________________________________________________________________ ,
{city} _____________ ,{state} ___, {zip code}________,{telephone number} ____________________ .

Florida Supreme Court Approved Family Law Form 12.941(d), Emergency Verified Motion for Child Pick-Up Order
(03/15)
- 264 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
,
Petitioner,

and

,
Respondent.

ORDER TO PICK-UP MINOR CHILD(REN)

An Emergency Verified Motion for Child Pick-Up Order has been filed by ____ Petitioner
____ Respondent, alleging facts which under existing law are determined to be sufficient to authorize
taking into custody the minor child(ren) named below. Based on this motion, this Court makes the
following findings, notices, and conclusions:

JURISDICTION
This Court has jurisdiction over issues surrounding the minor child(ren) listed below based on the
following:
{Choose all that apply}
a. ____ This Court exercised and continues to exercise original jurisdiction over the minor children
listed below under the Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA),
specifically, section 61.514, Florida Statutes.
b. ____A certified out-of-state custody decree has been presented to this Court with a request for
full faith and credit recognition and enforcement under the Parental Kidnapping Prevention Act,
28 U.S.C. Section 1738A. This Court has jurisdiction to enforce this decree under the UCCJEA,
specifically sections 61.501-61.542, Florida Statutes.
c. ____ By operation of Florida law governing the custody of or time-sharing with child(ren) born
out of wedlock, this Court has jurisdiction over the child(ren) listed below because this (these)
child(ren) was (were) born in the State of Florida and no prior court action involving the minor
child(ren) has addressed a putative father’s rights to time-sharing or other parental rights. See
sections 742.031 and 744.301, Florida Statutes.
d. ____ Pursuant to the UCCJEA, specifically section 61.516, Florida Statutes, this Court has
jurisdiction to modify a custody decree of another state and has consulted with the Court which
took initial jurisdiction over the minor child(ren) to determine this authority.
e. ____ Other:

Florida Supreme Court Approved Family Law Form 12.941(e), Order to Pick-Up Minor Child(ren) (03/15)
- 265 -
NOTICE OF HEARING
Because this Order to Pick-Up Minor Child(ren) has been issued without prior notice to the non-movant
{name} ________________________________________________________ , all parties involved in
this matter are informed that they are scheduled to appear and testify at a hearing regarding this matter
on {date} , at {time} , at which time the Court will consider
whether the Court should issue a further order in this case, and whether other things should be ordered,
including who should pay the filing fees and costs. The hearing will be before the Honorable
{name} _________________________________________at {room name/number, location, address,
city} __________________________________________________________________________, Florida.
If a party does not appear, this order may be continued in force, extended, or dismissed, and/or
additional orders may be issued, including the imposition of court costs.

If you are a person with a disability who needs any accommodation in order
to participate in this proceeding, you are entitled, at no cost to you, to the
provision of certain assistance. Please contact:
__________________________________________________________________
{identify applicable court personnel by name, address, and telephone number}
at least 7 days before your scheduled court appearance, or immediately upon
receiving this notification if the time before the scheduled appearance is less
than 7 days; if you are hearing or voice impaired, call 711.
ORDER
This Court ORDERS AND DIRECTS any and all sheriffs of the State of Florida (or any other authorized law
enforcement officer in this state or in any other state) to immediately take into custody the minor
child(ren) identified below from anyone who has possession and:

1. ____ Place the minor child(ren) in the physical custody of {name}
________________ who ( ) may ( ) may not remove the minor child(ren)
from the jurisdiction of this Court.
OR
____ Accompany the minor child(ren) to the undersigned judge, if the minor child(ren) is (are) picked
up during court hours, for immediate hearing on the issue of custody or time-sharing. It is the
intention of this Court that the nonmoving party, minor child(ren), and movant appear immediately
upon service of this order before the undersigned judge, if available, or duty judge to conduct a hearing
as to which party is entitled to lawful custody of the minor child(ren) at issue. It is not the intention of
the court to turn over the child(ren) to the movant on an ex parte basis. Neither party should be
permitted to remove the child(ren) from the jurisdiction of this Court pending a hearing. If unable to
accomplish the above, the sheriff/officer shall take the child(ren) into custody and place them with the
Department of Children and Family Services of the State of Florida pending an expedited hearing herein.

Florida Supreme Court Approved Family Law Form 12.941(e), Order to Pick-Up Minor Child(ren) (03/15)
- 266 -
____ Place the minor child(ren) in the physical custody of {agency} _______________________
who shall contact the undersigned judge for an expedited hearing. The sheriff/officer shall not delay
the execution of this court order for any reason or permit the situation to arise where the nonmoving
party is allowed to remove the child(ren) from the jurisdiction of this court.

2. NEITHER PARTY OR ANYONE AT THEIR DIRECTION, EXCEPT PURSUANT TO THIS ORDER,
MAY REMOVE THE CHILD(REN) FROM THE JURISDICTION OF THIS COURT PENDING
FURTHER HEARING. SHOULD THE NONMOVING PARTY IN ANY WAY VIOLATE THE
MANDATES OF THIS ORDER IN THE PRESENCE OF THE LAW ENFORCEMENT OFFICER,
THIS OFFICER IS TO IMMEDIATELY ARREST AND INCARCERATE THE OFFENDING PARTY
UNTIL SUCH TIME AS THE OFFENDING PARTY MAY BE BROUGHT BEFORE THIS COURT
FOR FURTHER PROCEEDINGS.

All sheriffs of the State for Florida are authorized and ORDERED to serve (and/or execute) and enforce
this order in the daytime or in the nighttime and any day of the week, except as limited by this order
above.

Except as limited by the above, if necessary, the sheriff/officer is authorized to take all reasonable,
necessary, and appropriate measures to effectuate this order. The sheriff/officer shall not delay the
execution of this order for any reason or permit the situation to arise where the child(ren) is (are)
removed from the jurisdiction of this Court before execution of this order.

The minor child(ren) is (are) identified as follows:
Name Sex Birth date Race Physical Description

Current location/address of minor child(ren) or of party believed to have possession of the minor
child(ren):

DONE AND ORDERED on at _______________________, Florida {date} .

Florida Supreme Court Approved Family Law Form 12.941(e), Order to Pick-Up Minor Child(ren) (03/15)
- 267 -
CIRCUIT JUDGE

I certify that a copy of the {name of document(s)} ___________________________________________
was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the parties listed below on
{date}______________________________.

_______________________________
By: {Clerk of the Court or designee}
Petitioner (or his or her attorney)
Respondent (or his or her attorney)

Florida Supreme Court Approved Family Law Form 12.941(e), Order to Pick-Up Minor Child(ren) (03/15)
- 268 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY
LAW FORM 12.942(a)
MOTION FOR APPOINTMENT OF GUARDIAN AD LITEM (03/15)
When should this form be used?

This form may be used by either party in a family law case involving parenting, time–sharing, or
paternity of a minor child(ren) to request that the judge appoint a guardian ad litem to represent
the best interests of the minor child(ren). You should use this form if you feel that your child(ren)
needs someone other than you to ensure that both the judicial system and the other party(ies)
act(s) in the best interests of the child(ren). A guardian ad litem may be a volunteer who has been
trained and certified by the State of Florida Guardian ad Litem Program or an attorney who is a
member in good standing with The Florida Bar.

IMPORTANT INFORMATION REGARDING E-FILING

The Florida Rules of Judicial Administration now require that all petitions, pleadings, and documents
be filed electronically except in certain circumstances. Self-represented litigants may file petitions
or other pleadings or documents electronically; however, they are not required to do so. If you
choose to file your pleadings or other documents electronically, you must do so in accordance with
Florida Rule of Judicial Administration 2.525, and you must follow the procedures of the judicial
circuit in which you file. The rules and procedures should be carefully read and followed.

What should I do next?

A copy of this form must be mailed, e-mailed, or hand delivered to the other party in your case.

It is possible that there will be a hearing on your motion. The judge may want to hear the reasons
you feel an appointment of a guardian ad litem is necessary, or, the other party may object to your
motion. If a hearing is required, check with the clerk of court, family law court staff, or judicial
assistant for information on the local procedure for scheduling a hearing. When you know the date
and time of your hearing, you should file Notice of Hearing (General), Florida Supreme Court
Approved Family Law Form 12.923, or other appropriate notice of hearing form, and provide a copy
to the other party.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions for Florida Supreme Court Approved Family Law Form 12.942(a), Motion for Appointment of
Guardian ad Litem (03/15)
- 269 -
After the initial service of process of the petition or supplemental petition by the Sheriff or certified
process server, the Florida Rules of Judicial Administration now require that all documents required
or permitted to be served on the other party must be served by electronic mail (e-mail) except in
certain circumstances. You must strictly comply with the format requirements set forth in the
Rules of Judicial Administration.

SELF-REPRESENTED LITIGANTS MAY SERVE DOCUMENTS BY E-MAIL; HOWEVER, THEY ARE NOT
REQUIRED TO DO SO. If a self-represented litigant elects to serve and receive documents by e-mail,
the procedures must always be followed once the initial election is made.
To serve and receive documents by e-mail, you must designate your e-mail addresses by using the
Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family Law
Form 12.915, and you must provide your e-mail address on each form on which your signature
appears. Please CAREFULLY read the rules and instructions for: Certificate of Service (General),
Florida Supreme Court Approved Family Law Form 12.914; Designation of Current Mailing and E-
mail Address, Florida Supreme Court Approved Family Law Form 12.915; and Florida Rule of Judicial
Administration 2.516.

Where can I look for more information?

Before proceeding, you should read “General Information for Self-Represented Litigants” found at
the beginning of these forms. You may also want to contact the Guardian ad Litem Program office
in your area or see sections 61.401-405, Florida Statutes.

Special notes...

Order... These family law forms contain an Order Appointing a Guardian ad Litem, Florida Supreme
Court Approved Family Law Form 12.942(b), which the judge may use. You should check with the
clerk, family law intake staff, or judicial assistant to see if you need to bring a blank order form with
you to the hearing. If so, you should type or print the heading, including the circuit, county, case
number, division, and the parties’ names, and leave the rest blank for the judge to complete at your
hearing or trial.

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of Disclosure from Nonlawyer, Florida Family Law
Rules of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill out
these forms also must put his or her name, address, and telephone number on the bottom of the
last page of every form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.942(a), Motion for Appointment of
Guardian ad Litem (03/15)
- 270 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
,
Petitioner,

and

,
Respondent.

MOTION FOR APPOINTMENT OF GUARDIAN AD LITEM
_____ Petitioner _____ Respondent requests that the Court enter an order appointing a guardian ad
litem with all powers, privileges, and responsibilities authorized in section 61.403, Florida Statutes,
and states:

1. The following minor child(ren) is (are) subject to this proceeding:
Name Birth date Age Sex Location/Address

2. Verified allegations of child abuse or neglect as defined in sections 39.01(2) or (45), Florida
Statutes, _____ HAVE _____ HAVE NOT been made in this case.

3. The matters before the Court regarding the minor child(ren) are _____ establishment or
_____ modification of:
a. sole/shared parental responsibility
b. Parenting Plan and time-sharing schedule
c. Other:__________________________________________________________

Florida Supreme Court Approved Family Law Form 12.942(a), Motion for Appointment of
Guardian ad Litem (03/15)
- 271 -
4. It is in the best interests of the minor child(ren) that a guardian ad litem be appointed to
advance the best interests of the minor child(ren) because:

____________________________________________________________________________

I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand
delivered to the person(s) listed below on {date} ______________________.

Other party or his/her attorney:
Name:
Address:
City, State, Zip:
Fax Number:
Designated E-mail Address(es):__________________
__________________________________________

_____________________________________________
Signature of Party
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es):_________________
_______________________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent
This form was completed with the assistance of:
{name of individual} ______________________________________________________________ ,
{name of business}____________________________________________________________ ,
{address} ______________________________________________________________________ ,
{city} _________,{state} _________, {zip code}________,{telephone number}________________ .
Florida Supreme Court Approved Family Law Form 12.942(a), Motion for Appointment of
Guardian ad Litem (03/15)
- 272 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
,
Petitioner,

and

,
Respondent.

ORDER APPOINTING GUARDIAN AD LITEM
Upon _____ Petitioner’s _____ Respondent’s motion or the _____ Court’s own motion to appoint a
guardian ad litem for the minor child(ren) herein and the Court finding that:

a. _____ verified allegations of child abuse or neglect as defined in sections 39.01(2) or (45),
Florida Statutes, have been made and are determined to be well-founded,
OR
b. _____ it is otherwise in the best interests of the child(ren) that a guardian ad litem be appointed to
advance the best interests of the minor child(ren) because:

it is thereupon ORDERED as follows:

1. A guardian ad litem shall be appointed for the minor child(ren), {name(s)}
,
now residing at {street address} .

2. The State of Florida Guardian ad Litem Program for the ____ Judicial Circuit shall assign a
certified guardian ad litem for the minor child(ren). Upon filing of the Notice of Acceptance, the
guardian ad litem can be served c/o Guardian ad Litem Program, {address} _______________
____________________________________________________________________________.
Pursuant to the State of Florida Guardian ad Litem Standards of Operation adopted by the
Supreme Court of Florida, if the Guardian ad Litem Program is appointed in the absence of a
well-founded allegation of abuse or neglect, an automatic discharge by the Court will occur upon
filing of a Motion to Discharge by the Program if the Program does not have sufficient volunteer
and/or supervisory resources available to accommodate this appointment.
OR

{Name} , an attorney in good standing with The Florida
Bar, is appointed to serve as a private guardian ad litem for the above minor child(ren). The fees of the
private guardian shall be paid by:

Florida Supreme Court Approved Family Law Form 12.942(b), Order Appointing Guardian ad Litem (03/15)

- 273 -
_____ Petitioner _____ Respondent _____ each party equally _____ other, {specify}
.

3. The guardian ad litem is a party to any judicial proceeding from the date of this order until the
date of discharge and shall have all of the powers, privileges, and responsibilities authorized in
section 61.403, Florida Statutes, to the extent necessary to advance the best interests of the minor
child(ren).

4. The guardian ad litem must be provided with copies of all pleadings, notices, stipulations, and
other documents filed in this action and is entitled to reasonable notice before any action
affecting the child(ren) is taken by either of the parties, their counsel, or the Court. The
guardian ad litem is entitled, through counsel, to be present at any depositions, hearings, or
other proceedings concerning the minor child(ren).

5. The guardian ad litem may investigate the allegations of the pleadings affecting the minor
child(ren), and after proper notice may interview witnesses or any other person having
information concerning the welfare of the minor child(ren).

6. The guardian ad litem shall maintain any information received from any source described in
section 61.403(2), Florida Statutes, as confidential and shall not disclose such information
except in reports to the Court served upon both parties to this cause and their counsel, or as
directed by the Court.

7. The parties, or any other person entrusted by the parties with the care of the minor child(ren)
shall allow the guardian ad litem access to the minor child(ren) at reasonable times and
locations and no person shall obstruct the guardian ad litem from the minor child(ren).

8. The guardian ad litem shall submit his or her recommendations to the Court regarding any
stipulation or agreement, whether incidental, temporary, or permanent, which affects the
interest or welfare of the minor child(ren), within 10 days after the date the stipulation or
agreement is served upon the guardian ad litem.

9. The guardian ad litem shall file a written report with the Court, which may include
recommendations and a statement of the wishes of the minor child(ren). The report must be
filed and served on all parties at least 20 days prior to the hearing at which it will be presented
unless the Court waives such time period. The guardian ad litem’s report shall address the
following areas, subject to any conditions ordered by this Court:
a. ____ parental responsibility of child(ren);
b. ____ residence of child(ren);
c. ____ time-sharing including times and locations;
d. ____ appearance of child(ren) at depositions/hearings;
e. ____ relocation;
f. ____ best interests of child(ren) regarding scientific tests; and/or
g. ____ other _________________________________________________________

This appointment is subject to the following conditions:

Florida Supreme Court Approved Family Law Form 12.942(b), Order Appointing Guardian ad Litem (03/15)

- 274 -
10. The guardian ad litem is automatically discharged without further order 30 days after the entry
of a final order or judgment in this proceeding, unless otherwise ordered by the Court.

DONE AND ORDERED at __________________________, Florida, on ______.

CIRCUIT JUDGE

_______________________________________
By: {Clerk of Court, Designee, or Judicial Assistant}

Petitioner (or his or her attorney)
Respondent (or his or her attorney)
________ Guardian ad Litem Program
________ Other:

Florida Supreme Court Approved Family Law Form 12.942(b), Order Appointing Guardian ad Litem (03/15)

- 275 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.943,
MOTION TO DEVIATE FROM CHILD SUPPORT GUIDELINES (03/15)

When should this form be used?

Child support in Florida is determined by the child support guidelines found in section 61.30, Florida
Statutes. The court, at its discretion, may raise or lower the child support guidelines amount by up to
5%. In addition, the court may raise or lower the guidelines support amount by more than 5%, if written
reasons are given for the adjustment. The court may make these additional adjustments based on
certain considerations, which are reflected in this form. You should review this form to determine if any
of the reasons for adjusting the child support guidelines amount apply to your situation and you should
complete this form only if you want the court to order more child support or less child support than the
amount required by the child support guidelines.

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?

A copy of this form must be mailed, e-mailed, or hand delivered to the other party in your case.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions for Florida Supreme Court Approved Family Law Form 12.943, Motion to Deviate from Child Support
Guidelines (03/15)
- 276 -
SELF-REPRESENTED LITIGANTS MAY SERVE DOCUMENTS BY E-MAIL; HOWEVER, THEY ARE NOT
REQUIRED TO DO SO. If a self-represented litigant elects to serve and receive documents by e-mail, the
procedures must always be followed once the initial election is made.

Where can I look for more information?

Before proceeding, you should read General Information for Self-Represented Litigants found at the
beginning of these forms. For further information, see section 61.30, Florida Statutes.

Special notes...

More information on the child support guidelines as well as a chart for converting income and expenses
to monthly amounts if paid or incurred on other than a monthly basis is contained in the instructions to
Florida Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or (c), and
the Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e).
With this form you must also file the following, if not already filed:
 Florida Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or
(c).
 Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e). (If
you do not know the other party’s income, you should file this worksheet as soon as you receive
a copy of his or her financial affidavit.)

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.943, Motion to Deviate from Child Support
Guidelines (03/15)
- 277 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
,
Petitioner,

and

,
Respondent.

MOTION TO DEVIATE FROM CHILD SUPPORT GUIDELINES
_____ Petitioner _____ Respondent requests that the Court enter an order granting the following:

SECTION I
[Choose A or B]
A.____ MORE child support than the amount required by the child support guidelines. The Court
should order MORE child support than the amount required by the child support guidelines
because of: [Choose all that apply to your situation]
1. ____Extraordinary medical, psychological, educational, or dental expenses;
2. ____Seasonal variations in one or both parent's income or expenses
3. ____Age(s) of the child(ren), taking into account the greater needs of older child(ren);
4. ____Special needs, such as costs that may be associated with the disability of a child or
child(ren), that have traditionally been met within the family budget even though the
fulfilling of those needs will cause support to exceed the presumptive amount established
by the guidelines;
5. ____Total available assets of obligee, obligor, and the child(ren);
6. ____Impact of the Internal Revenue Service Child & Dependent Care Tax Credit, Earned
Income Tax Credit, and dependency exemption and waiver of that exemption;
7. ____The Parenting Plan, such as where the child or children spend a significant amount of
time, but less than 20 percent of the overnights, with one parent, thereby reducing the
financial expenditures incurred by the other parent, or the refusal of a parent to become
involved in the activities of the child(ren) has increased the financial expenditure incurred by
the obligee;
8. ____The obligee parent’s low income and ability to maintain the basic necessities of the
home for the child(ren);
9. ____The likelihood that either parent will actually exercise the time-sharing schedule set
forth in the parenting plan and/or whether all the children are exercising the same time-
sharing schedule;
Florida Supreme Court Approved Family Law Form 12.943, Motion to Deviate from Child Support Guidelines
(03/15)
- 278 -
10. ____Any other adjustment that is needed to achieve an equitable result, which may include
reasonable and necessary expenses or debts jointly incurred during the marriage.
Explain any items marked above: _______________________________________________
___________________________________________________________________________
___________________________________________________________________________.

B.____ LESS child support than the amount required by the child support guidelines. The Court should
order LESS child support than the amount required by the child support guidelines because of: [Choose
all that apply to your situation]
1. ____ Extraordinary medical, psychological, educational, or dental expenses;
2. ____Independent income of child(ren), excluding the child(ren)’s SSI (supplemental security
income)
3. ____Payment of support for a parent which has been regularly paid and for which there is
a demonstrated need;
4. ____Seasonal variations in one or both parent's income or expenses;
5. ____Age of the child(ren), taking into account the greater needs of older child(ren);
6. ____ Total available assets of obligee, obligor, and child(ren);
7. _____Impact of the Internal Revenue Service Child & Dependent Care Tax Credit, Earned
Income Tax Credit, and dependency exemption and waiver of that exemption;
8. ____ Application of the child support guidelines which requires the obligor to pay more
than 55% of gross income for a single support order;
9. ____ Residency of subsequently born or adopted child(ren) with the obligor, include
consideration of the subsequent spouse's income;
10. ____ The Parenting Plan, where the child(ren) spend a significant amount of time, but less
than 20 percent of the overnights, with one parent, thereby reducing the financial
expenditures incurred by the other parent; or the refusal of a parent to become involved in
the activities of the child(ren)has reduced the financial expenditure of that parent;
11. ____Any other adjustment that is needed to achieve an equitable result, which may include
reasonable and necessary expenses or debts jointly incurred during the marriage.
Explain any items marked above:___________________________ _________________

SECTION II. INCOME AND ASSETS OF CHILD(REN) COMMON TO BOTH PARTIES
List the total of any independent income or assets of the child(ren) common to both parties (income
from Social Security, gifts, stocks/bonds, employment, trust fund(s), investment(s), etc.). Attach an
explanation.
TOTAL VALUE OF ASSETS OF CHILD(REN) $ ____________
TOTAL MONTHLY INCOME OF CHILD(REN) $ ____________

Florida Supreme Court Approved Family Law Form 12.943, Motion to Deviate from Child Support Guidelines
(03/15)
- 279 -
SECTION III. EXPENSES FOR CHILD(REN) COMMON TO BOTH PARTIES
All amounts must be MONTHLY. See the instructions with this form to figure out money amounts for
anything that is NOT paid monthly. Attach more paper, if needed. Items included under “other” should
be listed separately with separate dollar amounts.
1. $ _______ Monthly nursery, babysitting, or other child care
2. $ _______ Monthly after-school care
3. $ _______ Monthly school tuition
4. $ _______ Monthly school supplies, books, and fees
5. $ _______ Monthly after-school activities
6. $ _______ Monthly lunch money
7. $ _______ Monthly private lessons/tutoring
8. $ _______ Monthly allowance
9. $ _______ Monthly clothing
10. $ _______ Monthly uniforms
11. $ _______ Monthly entertainment (movies, birthday parties, etc.)
12. $ _______ Monthly health and dental insurance premiums
13. $ _______ Monthly medical, dental, prescription charges (unreimbursed)
14. $ _______ Monthly psychiatric/psychological/counselor (unreimbursed)
15. $ _______ Monthly orthodontic (unreimbursed)
16. $ _______ Monthly grooming
17. $ _______ Monthly non-prescription medications/cosmetics/toiletries/sundries
18. $ _______ Monthly gifts from children to others (other children, relatives, teachers, etc.)
19. $ _______ Monthly camp or other summer activities
20. $ _______ Monthly clubs (Boy/Girl Scouts, etc.) or recreational fees
21. $ _______ Monthly visitation expenses (for nonresidential parent)
{Explain} ______________________________________________________
22. $ _______Monthly insurance (life, etc.)
{explain}: ______________________________________________________
Other {explain}:
23. _____________________________________________________________________
24. _____________________________________________________________________
25. _____________________________________________________________________
26. $____________TOTAL EXPENSES FOR CHILD(REN) COMMON TO BOTH PARTIES
(add lines 1 through 25)

Florida Supreme Court Approved Family Law Form 12.943, Motion to Deviate from Child Support Guidelines
(03/15)
- 280 -
I have filed, will file, or am filing with this form the following additional documents:
1. Florida Family Law Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form
12.902(b) or (c).
2. Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e).

I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand
delivered to the person(s) listed below on {date} ____________________.
Other party or his/her attorney:
Name: ____________________________________
Address: __________________________________
City, State, Zip: ______________________________
Fax Number: _______________________________
Designated E-Mail Address(es):___________________
__________________________________________

I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
motion and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.
__________________________________________
Signature of Party or his/her attorney
Printed Name: _______________________________
Address: ___________________________________
City, State, Zip: ______________________________
Telephone Number: ___________________________
Fax Number: ________________________________
Designated E-mail Address(es): _________________
__________________________________________
STATE OF FLORIDA
COUNTY OF __________________________

Sworn to or affirmed and signed before me on ________________ by __________________________

____________________________________________
NOTARY PUBLIC or DEPUTY CLERK

___________________________________________
[Print, type, or stamp commissioned name of notary or clerk.]
____ Personally known
____ Produced identification

Florida Supreme Court Approved Family Law Form 12.943, Motion to Deviate from Child Support Guidelines
(03/15)
- 281 -
Type of identification produced_____________________________________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent
This form was completed with the assistance of:
{name of individual} _________________________________________________________________,
{name of business} __________________________________________________________________,
{address} __________________________________________________________________________,
{city} ____________________, {state}___, {zip code}__________{telephone number}_____________.

Florida Supreme Court Approved Family Law Form 12.943, Motion to Deviate from Child Support Guidelines
(03/15)
- 282 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.944(a),
MOTION FOR TESTIMONY AND ATTENDANCE OF MINOR CHILD(REN)
(03/15)

When should this form be used?

Rule 12.407, Florida Family Law Rules, provides that minor children may not be deposed (have their
deposition taken), brought to court to appear as a witness or to attend a hearing, or subpoenaed to
appear at a hearing without prior order of the court. This rule applies in all cases except when there is
an emergency or the case is an uncontested adoption. You should use this form to request that the
court enter an order authorizing a minor child(ren) to appear at a court proceeding.

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?

A copy of this form must be mailed, e-mailed, or hand delivered to any other party(ies) in your case,
including the guardian ad litem, if one has been appointed.

It is possible that there will be a hearing on your motion. The judge may want to hear the reasons you
feel this motion should be granted, or the other party may object to your motion. If a hearing is
required, check with the clerk of court, judicial assistant, or family law intake staff for information on
the local procedure for scheduling a hearing. When you know the date and time of your hearing, you
should file Notice of Hearing (General),Florida Supreme Court Approved Family Law Form 12.923, or
other appropriate notice of hearing form, and provide a copy to any other party.

Where can I look for more information?

Instructions for Florida Supreme Court Approved Family Law Form 12.944(a), Motion for Testimony and
Attendance of Minor Child(ren) (03/15)
- 283 -
Before proceeding, you should read General Information for Self-Represented Litigants found at the
beginning of these forms. For further information, see rule 12.407, Florida Family Law Rules of
Procedure.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Special notes...

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.944(a), Motion for Testimony and
Attendance of Minor Child(ren) (03/15)
- 284 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
__,
Petitioner,

and

___,
Respondent.

MOTION FOR TESTIMONY AND ATTENDANCE OF MINOR CHILD(REN)
_____ Petitioner _____Respondent requests that the Court enter an order authorizing one or more of
the actions listed below related to the following minor child(ren):
Name Birth date Age

[Indicate all that apply]
1.____ Minor child(ren), {name(s)} ,
be subpoenaed to appear at hearing now scheduled for {date} .
2.____ Minor child(ren), {name(s)} ,
attend deposition of {name(s)} now scheduled for{date} at
{location} __________________________________________________________________.

3. ____ Minor child(ren)’s, {name(s)} ,
deposition be taken on {date} at {location} .
4. ____ Minor child(ren), {name(s)} ,
be brought to court to attend hearing now scheduled for {date} at
{location} .
5. ____ Minor child(ren), {name(s)} ,
be brought to court to testify in a hearing now scheduled for {date} at
{location} .

Florida Supreme Court Approved Family Law Form 12.944(a), Motion for Testimony and Attendance of Minor
Child(ren) (03/15)
- 285 -
The Court should do this because:

I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand
delivered to the person(s) listed below on {date} .

Other party or his/her attorney:
Name:
Address:
City, State, Zip: _______
Fax Number:
Designated E-mail Address(es): ______________________
________________________________________________

Signature of Party
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es):_____________________
______________________________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the {choose only one} ( ) Petitioner ( ) Respondent
This form was completed with the assistance of:
{name of individual} ____________________________________________________________________ ,
{name of business}______________________________________________________________________,
{address} _____________________________________________________________________________,
{city} ________________,{state}_______,{zip code} , {telephone number} .

Florida Supreme Court Approved Family Law Form 12.944(a), Motion for Testimony and Attendance of Minor
Child(ren) (03/15)
- 286 -
IN THE CIRCUIT COURT OF THE ____________________ JUDICIAL CIRCUIT,
IN AND FOR ____________________ COUNTY, FLORIDA

Case No.: __________________________
Division: ___________________________

______________________________________,
Petitioner,

and

_____________________________________,
Respondent.

ORDER FOR TESTIMONY AND APPEARANCE OF MINOR CHILD(REN)

Upon motion of ______ Petitioner _____ Respondent for testimony or attendance of minor child(ren) in
these proceedings, and the Court finding that a showing of good cause has been made in support of the
motion, it is

ORDERED that
{Indicate all that apply}
1. _____ Minor child(ren),
{name(s)}___________________________________________________,
be subpoenaed to appear at hearing now scheduled for {date} ___________________________.

2. _____ Minor child(ren), {name(s)}
___________________________________________________,
attend deposition of {name(s)} ______________________________________ now scheduled for {date}
______________at {location} _________________________________________________.

3. _____ Minor child(ren)’s, {name(s)} _________________________________________________,
deposition be taken on {date} ______________at {location} ______________________________
_______________________________________________________________________________.

4. _____ Minor child(ren), {name(s)} __________________________________________________
be brought to court to attend hearing now scheduled for {date} ________________ at {location}
_______________________________________________________________________________.

Florida Supreme Court Approved Family Law Form 12.944(b), Order for Testimony and Attendance of Minor
Child(ren) (03/15)
- 287 -
5. _____Minor child(ren), {name(s)} _________________________________________________,
be brought to court to testify in a hearing now scheduled for {date} _____________ at {location}
_______________________________________________________________________________.
If the minor child or the person bringing the child is a person with a
disability, who needs any accommodation in order to participate in this
proceeding, either is entitled, at no cost to them, to the provision of certain
assistance. Please contact:
__________________________________________________________________
{identify applicable court personnel by name, address, and telephone number}
at least 7 days before the scheduled court appearance, or immediately upon
receiving this notification if the time before the scheduled appearance is less
than 7 days; if you are hearing or voice impaired, call 711.
Conditions or limitations concerning the minor child(ren), if any, include: _________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

DONE AND ORDERED at _________________________, Florida on ______________________.

______________________________________________
CIRCUIT JUDGE

I certify that a copy of the {name of document} ___________________________________ was
( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the parties and entities listed
below on {date} ______________________________.

_________________________________________
By: {Clerk of court, designee, or judicial assistant}

Florida Supreme Court Approved Family Law Form 12.944(b), Order for Testimony and Attendance of Minor
Child(ren) (03/15)
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Petitioner (or his or her attorney)
Respondent (or his or her attorney)

Florida Supreme Court Approved Family Law Form 12.944(b), Order for Testimony and Attendance of Minor
Child(ren) (03/15)
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INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.947(a),
MOTION FOR TEMPORARY SUPPORT, TIME-SHARING, AND OTHER
RELIEF WITH DEPENDENT OR MINOR CHILD(REN) (03/15)

When should this form be used?

This form may be used by:

(1) The respondent or the petitioner in a pending dissolution of marriage action. For you to use
this form, a petition for dissolution of marriage must have already been filed. You should use
this form to ask the court to award any of the following: temporary use of assets; temporary
exclusive use of the marital home; temporary responsibility for liabilities/debts; temporary
spousal support (alimony); temporary time-sharing schedule with minor child(ren); temporary
child support; and other relief.

(2) The petitioner in a pending action for support unconnected with dissolution. For you to use this
form, a petition for support unconnected with dissolution of marriage must have already been
filed. You should use this form to ask the court to award temporary spousal support (alimony)
and/or temporary child support.

This form should be typed or printed in black ink. After completing this form, you should file the original
with the clerk of the circuit court in the county where the petition for dissolution of marriage was filed
and keep a copy for your records.

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?

A copy of this form, along with all of the other forms required with this motion, must be mailed, e-

Instructions for Florida Supreme Court Approved Family Law Form 12.947(a), Motion for Temporary Support,
Time-Sharing, and Other Relief with Dependent or Minor Child(ren) (03/15)
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mailed, or hand delivered to the other party in your case. When you have filed all of the required forms,
you are ready to set a hearing on your motion. You should check with the clerk, family law intake staff,
or judicial assistant for information on the local procedure for scheduling a hearing. When you know
the date and time of your hearing, you should notify the other party using a Notice of Hearing
(General), Florida Supreme Court Approved Family Law Form 12.923, or other appropriate notice of
hearing form.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Where can I look for more information?

Before proceeding, you should read General Information for Self-Represented Litigants found at the
beginning of these forms. Words in bold underline in these instructions are defined there. For further
information, see chapter 61, Florida Statutes, rule 12.285, Florida Family Law Rules of Procedure, and
rule 1.610, Florida Rules of Civil Procedure.

Special notes...

If you use paragraph 1.c. of this form to ask the court to enter a temporary injunction, the court may
require you to post a bond.

With this form you must also file the following, if not already filed:

Instructions for Florida Supreme Court Approved Family Law Form 12.947(a), Motion for Temporary Support,
Time-Sharing, and Other Relief with Dependent or Minor Child(ren) (03/15)
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 Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida Supreme
Court Approved Family Law Form 12.902(d), if this case involves a minor or dependent
child(ren).
 Notice of Social Security Number, Florida Supreme Court Approved Family Law Form 12.902(j).
 Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e), if
you are asking that temporary child support be ordered. (If you do not know the other party’s
income, you may file this worksheet as soon as a copy of his or her financial affidavit has been
served on you.)

The parties seeking relief shall serve a financial affidavit (Florida Family Law Rules of Procedure Form
12.902 (b) or (c)) and certificate of compliance (Florida Family Law Rules of Procedure Form 12.932) with
the notice of hearing on the motion for temporary support and time-sharing.

Parenting Plan… If you have reached an agreement on either a temporary Parenting Plan or time-
sharing schedule, either one of the following proposed temporary Parenting Plans or a time-sharing
schedule, signed by both parties, should be filed. Parenting Plan, Florida Supreme Court Approved
Family Law Form 12.995(a), Safety-Focused Parenting Plan, Florida Supreme Court Approved Family
Law Form 12.995(b), or Relocation/Long Distance, Florida Supreme Court Approved Family Law Form
12.995(c). If you have not reached an agreement, a proposed Parenting Plan or temporary time-sharing
schedule may be filed for consideration by the Court.

Temporary Order... These family law forms contain a Temporary Order for Support, Time-Sharing, and
Other Relief with Dependent or Minor Child(ren), Florida Supreme Court Approved Family Law Form
12.947(b), which the judge may use. You should check with the clerk, family law intake staff, or judicial
assistant to see if you need to bring it with you to the hearing. If so, you should type or print the
heading, including the circuit, county, case number, division, and the parties’ names, and leave the rest
blank for the judge to complete at your hearing.

Case No.:
Division:
,
Petitioner,

and

,
Respondent.

MOTION FOR TEMPORARY SUPPORT, TIME-SHARING, AND OTHER
RELIEF WITH DEPENDENT OR MINOR CHILD(REN)
The _____ Petitioner _____ Respondent requests that the Court enter an order granting the following
temporary support:

{Complete all that apply}
1. Assets and Liabilities.
a. _____Award temporary exclusive use and possession of the marital home. {address}

The Court should do this because:

b. _____ Award temporary use and possession of marital assets. {Specify, without giving
account numbers}

The Court should do this because:

c. _____ Enter a temporary injunction prohibiting the parties from disposing of any marital
assets, other than ordinary and usual expenses. {Explain} ___________________________

The Court should do this because:

Florida Supreme Court Approved Family Law Form 12.947(a), Motion for Temporary Support, Time-Sharing, and
Other Relief with Dependent or Minor Child(ren) (03/15)
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d. _____ Require temporary payment of specific marital debts. {Explain without using
account numbers}____________________________________________________________

The Court should do this because:

2. Child(ren).
a. _____ Enter a temporary Parenting Plan with a time-sharing schedule for the parties’ minor
child(ren).
b. _____ Enter a temporary injunction prohibiting the parties from permanently removing the
child(ren) from the jurisdiction of the Court. The Court should do this because:

3. Support.
a. _____ Award temporary child support of $ per month.
b. _____ Award temporary spousal support/alimony of $ per month.
The Court should do this because:

4. Attorney’s fees and costs.
a. _____ Award temporary attorney’s fees of $ .
b. _____ Award temporary costs of $ ____.
The Court should do this because:

5. Other Relief. {specify}____________________________________________________________

6. A completed Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida
Supreme Court Approved Family Law Form 12.902(d), is filed with this motion or has already
been filed with the Court.

Florida Supreme Court Approved Family Law Form 12.947(a), Motion for Temporary Support, Time-Sharing, and
Other Relief with Dependent or Minor Child(ren) (03/15)
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7. A completed Notice of Social Security Number, Florida Supreme Court Approved Family Law
Form 12.902(j), is filed with this motion or has already been filed with the Court.

Florida Supreme Court Approved Family Law Form 12.947(a), Motion for Temporary Support, Time-Sharing, and
Other Relief with Dependent or Minor Child(ren) (03/15)
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8. I request that the Court hold a hearing on this matter and grant the relief specifically requested
and any other relief this Court may deem just and proper.

I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand
delivered to the person(s) listed below on {date} ______________________.

Other party or his/her attorney:
Name:
Address:
City, State, Zip:
Fax Number:
Designated E-mail Address(es):____________________
______________________________________________

Signature of Party or his/her attorney
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es): ____________________
_____________________________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent
This form was completed with the assistance of:
{name of individual}________________________________________________________________ ,
{name of business} __________________________________________________________________ ,
{address} ________________________________________________________ ,
{city} _______________,{state} _____, {zip code} ________, {telephone number} ________________ .

Florida Supreme Court Approved Family Law Form 12.947(a), Motion for Temporary Support, Time-Sharing, and
Other Relief with Dependent or Minor Child(ren) (03/15)
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IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.: ________________________
Division: ________________________
,
Petitioner,

and

,
Respondent.

TEMPORARY ORDER OF SUPPORT, TIME-SHARING, AND OTHER RELIEF
WITH DEPENDENT OR MINOR CHILD(REN)

This cause came before this Court for a hearing on a Motion for Temporary Support, Time-Sharing, and
Other Relief with Dependent or Minor Child(ren). The Court, having reviewed the file and heard the
testimony, makes these findings of fact and ORDERS as follows:

The Court has jurisdiction over the subject matter and the parties.

SECTION I. MARITAL ASSETS AND LIABILITIES
A. Injunction.
1. _____ Petitioner _____ Respondent is (are) prohibited and enjoined from disposing of any
marital assets without the written permission of the other party or a court order. If
indicated here ____, the person(s) prohibited and enjoined from disposing of any marital
assets may continue to pay all ordinary and usual expenses.
2. The Court may enforce compliance with the terms of this injunction through civil and/or
indirect criminal contempt proceedings, which may include arrest, incarceration, and/or the
imposition of a fine.
3. Violation of this injunction may constitute criminal contempt of court.
4. Bond. This order is conditioned upon _____ Petitioner _____ Respondent posting bond in
the sum of $ with the clerk of this Court.

B. Temporary Use of Assets.
1. The assets listed below are temporarily determined to be marital assets. Each party shall
temporarily have the use of, as his/her own, the assets awarded in this section, and the
other party shall temporarily have no further use of said assets. Any personal property not
listed below shall be for the use of party currently in possession of that item(s), and he or
she may not dispose of that item(s) without the written permission of the other party or a
court order.

Florida Supreme Court Approved Family Law Form 12.947(b), Temporary Order of Support, Time-Sharing, and
Other Relief with Dependent or Minor Child(ren) (03/15)
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Wife Husband
ASSETS: DESCRIPTION OF ITEM(S) (Please describe each item as clearly as Shall Have Shall Have
possible. You do not have to list account numbers.) Temporary Temporary
Use Use
Automobiles

Furniture & furnishings in home

Furniture & furnishings elsewhere

Jewelry
Business interests

Other Assets

C. Temporary Responsibility for Liabilities/Debts.
1. The liabilities listed below are temporarily determined to be marital. Each party shall pay as
his or her own the marital liabilities indicated below and shall keep said payments current.
The other party shall temporarily have no further responsibility for the payment of these
debts.
LIABILITIES: DESCRIPTION OF DEBT(S)(Please describe each item as Current
clearly as possible. You do not have to list account numbers.) Amount Wife Husband
Owed Shall Pay Shall Pay
Mortgages on real estate: (home) $ $ $

Florida Supreme Court Approved Family Law Form 12.947(b), Temporary Order of Support, Time-Sharing, and
Other Relief with Dependent or Minor Child(ren) (03/15)
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LIABILITIES: DESCRIPTION OF DEBT(S)(Please describe each item as Current
clearly as possible. You do not have to list account numbers.) Amount Wife Husband
Owed Shall Pay Shall Pay

Charge/credit card accounts

Auto loan
Auto loan
Bank/Credit Union loans

Money owed (not evidenced by a note)

Other

SECTION II. TEMPORARY EXCLUSIVE USE AND POSSESSION OF HOME
[Indicate all that apply]
1. _____ Petitioner _____Respondent shall have temporary exclusive use and possession of the
dwelling located at: {address}

until: {date or event}
.

2. _____ Petitioner _____Respondent may make a visit to the premises described in the paragraph
above for the purpose of obtaining his or her clothing and items of personal health and hygiene
and to obtain any items awarded in this order. This visit shall occur after notice to the person
granted temporary exclusive use and possession of the dwelling and at the earliest convenience
of both parties.

3. _____Other: ____________________________________________________________________

SECTION III. TEMPORARY PARENTAL RESPONSIBILITY AND TIME-SHARING WITH DEPENDENT OR
MINOR CHILD(REN)

Florida Supreme Court Approved Family Law Form 12.947(b), Temporary Order of Support, Time-Sharing, and
Other Relief with Dependent or Minor Child(ren) (03/15)
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1. Jurisdiction. The Court has jurisdiction to determine temporary parental responsibility and
time-sharing for the parties’ minor child(ren) listed in paragraph 2 below.

2. The parties’ dependent or minor child(ren) is (are):

Name Birth date

3. Temporary Parental Responsibility for the Minor Child(ren).
{Choose only one}
a. _____ The parties shall have temporary shared parental responsibility for the parties’
minor child(ren).

b. _____ Mother _____ Father shall have temporary sole parental responsibility for the
parties’ minor child(ren). Temporary shared parental responsibility would be detrimental to
the child(ren) at this time because: ___________________________________________

c. _____ Mother_____Father shall have ultimate decision making authority regarding the
following:______________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
.

d. Other provisions: __________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

4. Temporary Time-sharing Schedule with Minor Child(ren). The parent(s) shall have:
{Choose only one}
a. _____ reasonable time-sharing schedule with the parties’ minor child(ren) as agreed to by
the parties, subject to any limitations in paragraph 5 below. The Court reserves jurisdiction
to set a specific schedule.
b. _____the following specified time-sharing schedule with the parties’ minor child(ren),
subject to any limitations set out in paragraph 5 below: {specify days and times}

Florida Supreme Court Approved Family Law Form 12.947(b), Temporary Order of Support, Time-Sharing, and
Other Relief with Dependent or Minor Child(ren) (03/15)
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_________________________________________________________________________
___________________________________________________________________________

Mother’s Temporary Time-Sharing Schedule.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________.

Father’s Temporary Time-sharing Schedule.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________.

c. _____ Time-sharing in accordance with the temporary Parenting Plan attached as
Exhibit _____.

d. _____ Mother _____Father shall have no contact with the parties’ minor child(ren) until
further order of the Court, due to the existing conditions that are detrimental to the welfare
of the minor child(ren): {explain}: _______________________________________________

5. Limitations on Time-sharing. Neither parent shall take the child(ren) from the other parent, any
child care provider, or other person entrusted by the other parent with the care of the child(ren)
without the agreement of the other party during the other party’s time-sharing. The above
time-sharing shall be:
[Indicate if applicable]
a. _____ supervised by a responsible adult who is mutually agreeable to the parties. If the
parties cannot agree, the supervising adult shall be: {name} __________________________.
b. _____ at a supervised visitation center located at: {address} ________________________
,
subject to the available times and rules of the supervised visitation center. The cost of such visits shall
be paid by _____ Mother _____ Father _____ Both.

6. Communication Arrangements, Parental Responsibility and Time-sharing with Minor
Child(ren).
[Indicate if applicable]
______ The parties’ communications to arrange time-sharing and discuss issues relating to the
child(ren) (if temporary shared parenting, or time-sharing is provided in paragraph 3 above) are
restricted as follows: _____ telephone, _____ fax, _____ e-mail, or _____ letter, _____ a responsible

Florida Supreme Court Approved Family Law Form 12.947(b), Temporary Order of Support, Time-Sharing, and
Other Relief with Dependent or Minor Child(ren) (03/15)
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person shall coordinate the time-sharing arrangements of the minor child(ren). If the parties cannot
agree, the responsible person shall be: {name}

other conditions for arrangements or discussions: {explain}
_________________________________________________________________________
________________________________________________________________________
________________________________________________________________________ .

7. Exchange of Minor Child(ren). The exchange of the minor child(ren) shall be on time as
scheduled and as agreed to by the parties. The following conditions, if indicated below, shall
also apply.
{Indicate all that apply}
a. _____ The parties shall temporarily exchange the child(ren) at the following
location(s):

b. _____ Mother _____Father shall not get out of the vehicle, and the other parent shall not
approach the vehicle, during the time the child(ren) are exchanged.
c. _____ A responsible person shall conduct all exchanges of the child(ren). ( )
Mother
( ) Father shall not be present during the exchange. If the parties cannot agree, the
responsible person shall be: {name} __________________________________________
d. _____ Other conditions for exchange of the child(ren) are as follows:
________________

8. _____ Injunction Prohibiting Removing the Child(ren). The Court hereby temporarily prohibits
and enjoins the _____ Mother _____Father _____ Both from removing the minor child(ren)
from the State of Florida without a court order or the written consent of the other party.

9. _____ Other Temporary Provisions Relating to the Minor Child(ren).

Florida Supreme Court Approved Family Law Form 12.947(b), Temporary Order of Support, Time-Sharing, and
Other Relief with Dependent or Minor Child(ren) (03/15)
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SECTION IV. TEMPORARY ALIMONY

1. _____ The Court denies the request(s) for temporary alimony.

2. _____ The Court finds that there is a need for, and that _____ Petitioner _____ Respondent,
hereinafter Obligor, has/had the present ability to pay temporary alimony as follows:
{Indicate all that apply}
a. ____ Temporary Periodic. Obligor shall pay temporary periodic alimony to Obligee in the
amount of $ per month, payable _____ in accordance with Obligor’s employer’s
payroll cycle, and in any event, at least once a month _____ other {explain}
,
beginning {date} ______________. This temporary periodic alimony shall continue until modified
by court order, the death of either party, or until, _________________________, {date or event}
whichever occurs first.

b. _____ Retroactive. Obligor shall pay retroactive alimony in the amount of $ for
the period of {date} _____ through {date} ________________,
which shall be paid pursuant to paragraph 4 below.

3. Reasons for Awarding/Denying Temporary Alimony Award.
The reasons for awarding/denying temporary alimony are as follows:
a. _____ length of the marriage of the party receiving temporary alimony: years________;
b. _____ age of party receiving temporary alimony: _______ years;
c. _____ health of party receiving temporary alimony: _____ excellent _____ good _____ poor
_____ other___________________________________________________________;
d. _____ other factors __________________________________________________________
___________________________________________________________________________

________ Please indicate here if additional pages are attached.

4. Retroactive Alimony. _____ Petitioner _____ Respondent shall pay to the other party the
temporary retroactive alimony of $ , as of {date} _____________. This amount shall
be paid in the amount of $ per month, payable in accordance with Obligor’s
employer’s payroll cycle, and in any event at least once a month ( ) other {explain} ________

beginning: {date} _________, until paid in full including statutory interest.

5. Insurance.
{Indicate all that apply}

Florida Supreme Court Approved Family Law Form 12.947(b), Temporary Order of Support, Time-Sharing, and
Other Relief with Dependent or Minor Child(ren) (03/15)
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a. _____ Health Insurance. _____ Petitioner _____ Respondent shall temporarily be required
to pay health insurance premiums for the other party not to exceed $ per month.
Further, _____ Petitioner _____ Respondent shall pay any reasonable and necessary
uninsured medical costs for the other party not exceed $ per year. As to these
uninsured medical expenses, the party who is entitled to reimbursement of the uninsured
medical expense shall submit request for reimbursement to the other party within 30 days,
and the other party shall, within 30 days after receipt, submit the applicable reimbursement
for that expense.
b. _____ Life Insurance (to secure payment of support). To secure the temporary alimony
obligations set forth in this order, the Obligor shall temporarily maintain life insurance on his/her life,
naming the Obligee as the sole irrevocable beneficiary, so long as reasonably available. This temporary
insurance shall be in the amount of at least $ _____ and shall remain in effect until this
temporary obligation for alimony terminates.

6. _____Other provisions relating to temporary alimony including any tax treatment and
consequences: _________________________________________________________________.
SECTION V. TEMPORARY CHILD SUPPORT

1. The Court finds that there is a need for temporary child support and that the _____ Mother
_____ Father (hereinafter Obligor) has the present ability to pay child support.
The amounts in the Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure
Form 12.902(e), filed by the _____ Mother _____ Father are correct

The Court makes the following findings:
The Mother’s net monthly income is $ ____.
The Father’s net monthly income is $ _____.
Monthly child care costs are $ _______.
Monthly health/dental insurance costs are $ __.

2. Amount.

Child support established at the rate of $_________per month for the _____children {total
number of minor or dependent children} shall be paid commencing ___________________
{month, day, year} and terminating _________________________ {month, day, year}. Child
support shall be paid in the amount of $__________ per ________ {week, month, other} which
is consistent with the Obligor’s current payroll cycle.

Upon the termination of the obligation of child support for one of the parties’ children, child support in
the amount of $________ for the remaining ______children {number of remaining children} shall be
paid commencing _________________ {month, day, year} and terminating _______________________
{month, day, year}. This child support shall be paid in the amount of $ _______ per _________ {week,

Florida Supreme Court Approved Family Law Form 12.947(b), Temporary Order of Support, Time-Sharing, and
Other Relief with Dependent or Minor Child(ren) (03/15)
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month, other} consistent with Obligor’s current payroll cycle.

{Insert schedule for the child support obligation, including the amount, and commencement and
termination dates, for the remaining minor or dependent children, which shall be payable as the
obligation for each child ceases. Please indicate whether the schedule ____appears below or____ is
attached as part of this form}
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________________
_______________________________________________________________________
______________________________________________________________________________.

The Obligor shall pay child support until all of the minor or dependent children: reach the age of 18;
become emancipated, marry, join the armed services, die, or become self-supporting; or until further
order of the court or agreement of the parties. The child support obligation shall continue beyond the
age of 18 and until high school graduation for any child who is dependent in fact, between the ages of
18 and 19, and is still in high school performing in good faith with a reasonable expectation of
graduation before age 19.

If the temporary child support ordered deviates from the guidelines by more than 5%, the factual
findings which support that deviation are:

3. Retroactive Child Support.
{Indicate if applicable}
_____Mother _____ Father shall pay to the other party the temporary retroactive child support of
$ , as of {date} . This amount shall be paid in the amount of
$ per month, payable in accordance with Obligor’s employer’s payroll cycle, and in any event
at least once a month ( ) other {explain} ______________________________
beginning {date} , until paid in full including statutory interest.

4. Insurance.
[Indicate all that apply]
_____Health/Dental Insurance. _____ Mother _____ Father shall be required to temporarily
maintain_____health _____ dental insurance for the parties’ minor child(ren), so long as
reasonable in cost and accessible to the child(ren). The party providing insurance shall be
required to convey cards showing coverage to the other party.

_____ Health _____ dental insurance is not reasonable in cost or accessible to the child(ren) at this time.

Florida Supreme Court Approved Family Law Form 12.947(b), Temporary Order of Support, Time-Sharing, and
Other Relief with Dependent or Minor Child(ren) (03/15)
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_____Reasonable and necessary uninsured medical/dental/prescription drug costs for the minor
child(ren) shall temporarily be assessed as follows:
_____ Shared equally by both parents.
_____ Prorated according to the child support guideline percentages.
_____ Other {explain}:

As to these uninsured medical/dental/prescription drug expenses, the party who incurs the expense
shall submit request for reimbursement to the other party within 30 days, and the other party, within 30
days of receipt, shall submit the applicable reimbursement for that expense, according to the schedule
of reimbursement set out in this paragraph.

5. _____Life Insurance (to secure payment of support). To secure the temporary child support
obligations in this order, _____ Petitioner _____ Respondent _____ Each party shall temporarily
maintain life insurance, in an amount of at least $ ______, on _____ his life _____ her
life _____ his/her life naming the _____ minor child(ren) as the beneficiary (ies) OR naming the
_____ Mother _____ Father_____ other {name}: ____________________________________ as trustee
for the minor child(ren), so long as reasonably available. The obligation to maintain the life insurance
coverage shall continue until the Court orders otherwise or until {date/event}
___________________________________________________________________________
.

6. IRS Income Tax Exemption(s). The assignment of any tax exemption for the child(ren) shall be as
follows: _________________________________________________
.

7. ____Other provisions relating to temporary child support: __________________________

SECTION VI. METHOD OF PAYMENT

Obligor shall pay any temporary court-ordered child support/alimony and arrears, if any, as follows:
1. Place of Payment

a. _____ Obligor shall pay temporary court-ordered support directly to either the State
Disbursement Unit or the central depository, as required by statute, along with any fee
required by statute.
b. _____ Both parties have requested and the court finds that it is in the best interests of the
child(ren) that temporary support payments need not be directed through either the State
Disbursement Unit or the central depository at this time; however, either party may
subsequently apply, pursuant to section 61.13(1)(d)3, Florida Statutes, to require payments
through either the State Disbursement Unit or the central depository.

Florida Supreme Court Approved Family Law Form 12.947(b), Temporary Order of Support, Time-Sharing, and
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2. Income Deduction.

_____ Immediate. Obligor shall pay through income deduction, pursuant to a separate Income
Deduction Order which shall be effective immediately. Obligor is individually responsible for paying this
temporary support obligation until all of said support is deducted from Obligor’s income. Until
temporary support payments are deducted from Obligor’s paycheck, Obligor is responsible for making
timely payments directly to the State Disbursement Unit or the Obligee, as previously set forth in this
order.

_____ Deferred. Income deduction is ordered this day, but it shall not be effective until a delinquency
of $ __, or, if not specified, an amount equal to one month’s obligation occurs. Income
deduction is not being implemented immediately based on the following findings: Income deduction is
not in the best interests of the child(ren) because: {explain}
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

AND
there is proof of timely payment of a previously ordered obligation without an income deduction order
in cases of modification,
AND
_____ there is an agreement by the Obligor to advise the Title IV-D agency, the clerk of court, and the
Obligee of any change in Payor and/or health insurance
OR
_____ there is a signed written agreement providing an alternative arrangement between the Obligor
and the Obligee and, at the option of the IV-D agency, by the IV-D agency in IV-D cases in which there is
an assignment of support rights to the state, reviewed and entered in the record by the court.

3. Bonus/one-time payments. _____ All _____% _____ No income paid in the form of a bonus or
other similar one-time payment, up to the amount of any arrearage or the remaining balance
thereof owed pursuant to this order, shall be forwarded to the Obligee pursuant to the payment
method prescribed above.

4. Other provisions relating to method of payment. _____________________________________

SECTION VII. TEMPORARY ATTORNEY’S FEES, COSTS, AND SUIT MONEY

1. _____Petitioner’s _____Respondent’s request(s) for temporary attorney’s fees, costs, and suit
money is (are) denied because _____________________________________________________

Florida Supreme Court Approved Family Law Form 12.947(b), Temporary Order of Support, Time-Sharing, and
Other Relief with Dependent or Minor Child(ren) (03/15)
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2. _____ The Court finds there is a need for and an ability to pay temporary attorney’s fees, costs,
and suit money. _____ Petitioner _____ Respondent is hereby ordered to pay to the other party
$ in temporary attorney’s fees, and $ _ in costs. The Court further finds
that the temporary attorney’s fees awarded are based on the reasonable rate of $
per hour and reasonable hours. Other provisions relating to temporary attorney’s fees,
costs, and suit money are as follows: _______________________________________________

SECTION VIII. OTHER PROVISIONS

Other Provisions:

DONE AND ORDERED in _______________________, Florida on {date} _______________________.

CIRCUIT JUDGE

I certify that a copy of this {name of document(s)} __________________________________________
was
( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the parties or entities listed
below on {date}______________________.

_______________________________________
By: {Clerk of Court or designee}

Petitioner (or his or her attorney)
Respondent (or his or her attorney)
_____State Disbursement Unit
_____Central depository

Florida Supreme Court Approved Family Law Form 12.947(b), Temporary Order of Support, Time-Sharing, and
Other Relief with Dependent or Minor Child(ren) (03/15)
- 308 -
_____Other:

Florida Supreme Court Approved Family Law Form 12.947(b), Temporary Order of Support, Time-Sharing, and
Other Relief with Dependent or Minor Child(ren) (03/15)
- 309 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.947(c)
MOTION FOR TEMPORARY SUPPORT AND OTHER RELIEF WITH NO
DEPENDENT OR MINOR CHILD(REN)(03/15)

When should this form be used?

This form may be used by:

(1) the respondent or the petitioner in a pending dissolution of marriage action. For you to use this
form, a petition for dissolution of marriage must have already been filed. You should use this form
to ask the court to award any of the following: temporary use of assets; temporary exclusive use of
the marital home; temporary responsibility for liabilities/debts; temporary spousal support
(alimony); and other relief.

(2) the petitioner in a pending action for support unconnected with a dissolution. For you to use this
form, a petition for support unconnected with a dissolution of marriage must have already been
filed. You should use this form to ask the court to award temporary spousal support (alimony).

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?

A copy of this form, along with all of the other forms required with this motion, must be mailed, e-
mailed, or hand delivered to the other party in your case. When you have filed all of the required forms,

Instructions for Florida Supreme Court Approved Family Law Form 12.947(c), Motion for Temporary Support and
Other Relief with No Dependent or Minor Child(ren) (03/15)
- 310 -
you are ready to set a hearing on your motion. You should check with the clerk, family law intake staff,
or judicial assistant for information on the local procedure for scheduling a hearing. When you know
the date and time of your hearing, you should notify the other party using a Notice of Hearing
(General), Florida Supreme Court Approved Family Law Form 12.923, or other appropriate notice of
hearing form.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Where can I look for more information?

Special notes...
If you use paragraph 1.c. of this form to ask the court to enter a temporary injunction, the court may
require you to post a bond.

With this form you must also file the following, if not already filed:

 Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or (c).

Instructions for Florida Supreme Court Approved Family Law Form 12.947(c), Motion for Temporary Support and
Other Relief with No Dependent or Minor Child(ren) (03/15)
- 311 -
(This must be filed within 45 days if not filed at the time of the petition.)
 Notice of Social Security Number, Florida Supreme Court Approved Family Law Form 12.902(j).
 Certificate of Compliance with Mandatory Disclosure, Florida Family Law Rules of Procedure
Form 12.932.

Temporary Order... These family law forms contain an Order for Temporary Support and Other Relief
with No Dependent or Minor Child(ren), Florida Supreme Court Approved Family Law Form 12.947(d),
which the judge may use. You should check with the clerk, family law intake staff, or judicial assistant to
see if you need to bring it with you to the hearing. If so, you should type or print the heading, including
the circuit, county, case number, division, and the parties’ names, and leave the rest blank for the judge
to complete at your hearing.

Nonlawyer… Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps
you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida
Family Law Rules of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill
out these forms also must put his or her name, address, and telephone number on the bottom of the
last page of every form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.947(c), Motion for Temporary Support and
Other Relief with No Dependent or Minor Child(ren) (03/15)
- 312 -
IN THE CIRCUIT COURT OF THE _____________________ JUDICIAL CIRCUIT,
IN AND FOR ______________________________ COUNTY, FLORIDA

Case No: ________________________
Division: ________________________

_________________________________,
Petitioner,
and

_________________________________,
Respondent.

MOTION FOR TEMPORARY SUPPORT AND OTHER RELIEF
WITH NO DEPENDENT OR MINOR CHILD(REN)

_____ Petitioner _____ Respondent requests that the Court enter an order granting the following
temporary support:

{Complete all that apply}
1. Assets and Liabilities.
a. _____ Award temporary exclusive use and possession of the marital home. {address} ______
______________________________________________________________________________
The Court should do this because: __________________________________________________
______________________________________________________________________________
______________________________________________________________________________

b. _____ Award temporary use and possession of marital assets. {Specify, without using account
numbers}______________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
The Court should do this because: __________________________________________________
______________________________________________________________________________
______________________________________________________________________________.
c. _____ Enter a temporary injunction prohibiting the parties from disposing of any marital assets,
other than ordinary and usual expenses. {Explain} ____________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Florida Supreme Court Approved Family Law Form 12.947(c), Motion for Temporary Support and Other Relief with
No Dependent or Minor Child(ren) (03/15)
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The Court should do this because: __________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
d. _____ Require temporary payment of specific marital debts. {Explain, without using account
numbers}
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
The Court should do this because: __________________________________________________
______________________________________________________________________________
______________________________________________________________________________

2. Support. Award temporary spousal support/alimony of $___________ per month.
The Court should do this because: _____________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

3. Other provisions relating to alimony including any tax treatment and
consequences:______________________________________________________________________
__________________________________________________________________________________

4. Attorney’s fees and costs.
a. _____ Award temporary attorney’s fees of $ __________.
b. _____ Award temporary costs of $__________.
The Court should do this because: __________________________________________________
______________________________________________________________________________
______________________________________________________________________________

5. Other Relief. {specify}______________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

6. A completed Certificate of Compliance with Mandatory Disclosure, Florida Family Law Rules of
Procedure Form 12.932, is filed with this motion or has already been filed with the Court.

7. A completed Notice of Social Security Number, Florida Supreme Court Approved Family Law Form
12.902(j), is filed with this motion or has already been filed with the Court.

Florida Supreme Court Approved Family Law Form 12.947(c), Motion for Temporary Support and Other Relief with
No Dependent or Minor Child(ren) (03/15)
- 314 -
I request that the Court hold a hearing on this matter and grant the relief specifically requested and any
other relief this Court may deem just and proper.

Florida Supreme Court Approved Family Law Form 12.947(c), Motion for Temporary Support and Other Relief with
No Dependent or Minor Child(ren) (03/15)
- 315 -
I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand
delivered to the person(s) listed below on {date} _______________________________.

Other party or his/her attorney:
Name: ________________________________________
Address: ______________________________________
City, State, Zip: _________________________________
Fax Number: __________________________________
Designated E-mail Address(es):____________________
_____________________________________________

___________________________________________
Signature of Party or his/her attorney
Printed Name: ________________________________
Address: _____________________________________
City, State, Zip: ________________________________
Telephone Number: ____________________________
Fax Number: __________________________________
Designated E-mail Address(es): ___________________
_____________________________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent
This form was completed with the assistance of:
{name of individual} _________________________________________________________________
,
{name of business} ___________________________________________________________________
,
{address} ___________________________________________________________________________
,
{city} ________________,{state} ____,{zip code}__________{telephone number} _________________
.

Florida Supreme Court Approved Family Law Form 12.947(c), Motion for Temporary Support and Other Relief with
No Dependent or Minor Child(ren) (03/15)
- 316 -
IN THE CIRCUIT COURT OF THE _____________________ JUDICIAL CIRCUIT,
IN AND FOR ______________________________ COUNTY, FLORIDA

Case No: ________________________
Division: ________________________

_________________________________,
Petitioner,
and

_________________________________,
Respondent.

ORDER FOR TEMPORARY SUPPORT AND OTHER RELIEF
WITH NO DEPENDENT OR MINOR CHILD(REN)
This cause came before this Court for a hearing on a Motion for Temporary Support and Other Relief
with No Dependent or Minor Child(ren). The Court, having reviewed the file and heard the testimony,
makes these findings of fact and ORDERS as follows:

The Court has jurisdiction over the subject matter and the parties.

2. The Court may enforce compliance with the terms of this injunction through civil and/or indirect
criminal contempt proceedings, which may include arrest, incarceration, and/or the imposition
of a fine.

3. Violation of this injunction may constitute criminal contempt of court.

4. Bond. This order is conditioned upon _____ Petitioner _____ Respondent posting bond in the
sum of $__________ with the clerk of this Court.

Florida Supreme Court Approved Family Law Form 12.947(d), Order for Temporary Support and Other Relief With
No Dependent or Minor Child(ren) (03/15)
- 317 -
below shall be for the use of party currently in possession of that item(s), and he or she may
not dispose of that item(s) without the written permission of the other party or a court order.

ASSETS: DESCRIPTION OF ITEM(S) Wife Husband
(Please describe each item as clearly as possible. You do not need to list Shall Have Shall Have
account numbers.) Temporary Temporary
Use Use
Automobiles

Furniture & furnishings in home

Furniture & furnishings elsewhere

Jewelry
Business interests

Other Assets

Florida Supreme Court Approved Family Law Form 12.947(d), Order for Temporary Support and Other Relief With
No Dependent or Minor Child(ren) (03/15)
- 318 -
LIABILITIES: DESCRIPTION OF DEBT(S)
(Please describe each item as clearly as possible. You do not need Current
to list account numbers.) Amount Wife Husband
Owed Shall Pay Shall Pay
Mortgages on real estate: (home) $ $ $

Charge/credit card accounts

Auto loan
Auto loan
Bank/Credit Union loans

Money owed (not evidenced by a note)

Other

SECTION II. TEMPORARY EXCLUSIVE USE AND POSSESSION OF HOME
{Indicate all that apply}
1. _____Petitioner _____ Respondent shall have temporary exclusive use and possession of the
dwelling located at: {address}

until {date or event}
.

2. _____ Petitioner _____Respondent may make a visit to the premises described in the
paragraph above for the purpose of obtaining his or her clothing and items of personal health
and hygiene and to obtain any items awarded in this order. This visit shall occur after notice to
the person granted temporary exclusive use and possession of the dwelling and at the earliest
convenience of both parties.

Florida Supreme Court Approved Family Law Form 12.947(d), Order for Temporary Support and Other Relief With
No Dependent or Minor Child(ren) (03/15)
- 319 -
3. _____ Other:
.
SECTION III. TEMPORARY ALIMONY
1. _____ The Court denies the request(s) for temporary alimony.
OR
2. _____The Court finds that there is a need for, and that _____ Petitioner _____ Respondent,
hereinafter Obligor, has/had the present ability to pay, temporary alimony as follows:
{Choose all that apply}
a. _____ Temporary Periodic. Obligor shall pay temporary periodic alimony to Obligee in the
amount of $__________ per month, payable ( ) in accordance with Obligor’s employer’s
payroll cycle, and in any event, at least once a month ( ) other {explain} ____________
,
beginning {date} __________. This temporary periodic alimony shall continue until modified by court
order, the death of either party, or until ,
_______________________________________________{date or event} whichever occurs
first.

b. _____ Retroactive. Obligor shall pay retroactive alimony in the amount of $__________ for
the period of {date} ___________________ through {date} _______________________,
which shall be paid pursuant to paragraph 4 below.

3. Reasons for Awarding/Denying Temporary Alimony Award. The reasons for awarding/denying
temporary alimony are as follows:
a_____ length of the marriage of the party receiving temporary alimony: years;
b._____ age of party receiving temporary alimony: ;
c._____health of party receiving temporary alimony: _____ excellent _____ good _____ poor
_____ other ____________________________________________________;
d._____ other factors

____ Please indicate here if additional pages are attached.

4. Retroactive Alimony. _____ Petitioner _____ Respondent shall pay to the other party the
temporary retroactive alimony of $___________, as of {date} ____________. This amount shall
be paid in the amount of $__________ per month, payable in accordance with Obligor’s
employer’s payroll cycle, and in any event at least once a month ( ) other {explain}: _______
,
beginning {date} ____________________________, until paid in full including statutory interest.

Florida Supreme Court Approved Family Law Form 12.947(d), Order for Temporary Support and Other Relief With
No Dependent or Minor Child(ren) (03/15)
- 320 -
5. Insurance.
[Indicate all that apply]
a. _____ Health Insurance. _____ Petitioner _____ Respondent shall temporarily be required
to pay health insurance premiums for the other party not to exceed $__________ per
month. Further, _____ Petitioner _____ Respondent shall pay any reasonable and
necessary uninsured medical costs for the other party not exceed $_____________per year.
As to these uninsured medical expenses, the party who is entitled to reimbursement of the
uninsured medical expense shall submit request for reimbursement to the other party
within 30 days, and the other party shall, within 30 days after receipt, submit the applicable
reimbursement for that expense.
b. _____ Life Insurance (to secure payment of support). To secure the temporary alimony
obligations set forth in this order, the Obligor shall temporarily maintain any existing life
insurance coverage on his/her life naming the Obligee as the sole irrevocable beneficiary, so
long as reasonably available. This temporary insurance shall be in the amount of at least
$__________ and shall remain in effect until this temporary obligation for alimony
terminates.

6. _____ Other provisions relating to temporary alimony including any tax treatment and
consequences: _________________________________________________________________

SECTION IV. METHOD OF PAYMENT

Obligor shall pay any temporary court-ordered alimony and arrears, if any, as follows:
1. Place of Payment.
[Indicate if applies]
a. _____ Obligor shall pay temporary court-ordered support directly to either the State
Disbursement Unit or the central depository, as required by statute, along with any fee
required by statute.
b. _____ Both parties have requested and the court finds that it is in the best interests that
temporary support payments need not be directed through either the State Disbursement
Unit or the central depository at this time; however, either party may subsequently apply,
pursuant to section 61.13(1)(d)3, Florida Statutes, to require payments through either the
State Disbursement Unit or the central depository.

2. Income Deduction.
[If applicable]
a. _____ Immediate. Obligor shall pay through income deduction, pursuant to a separate
Income Deduction Order which shall be effective immediately. Obligor is individually
responsible for paying this temporary support obligation until all of said support is deducted
from Obligor’s income. Until support payments are deducted from Obligor’s paycheck,
Obligor is responsible for making timely payments directly to the State Disbursement Unit or

Florida Supreme Court Approved Family Law Form 12.947(d), Order for Temporary Support and Other Relief With
No Dependent or Minor Child(ren) (03/15)
- 321 -
the Obligee, as previously set forth in this order.
b. _____ Deferred. Income deduction is ordered this day, but it shall not be effective until a
delinquency of $__________, or, if not specified, an amount equal to one month’s
obligation occurs. Income deduction is not being implemented immediately based on the
following findings: there are no minor child(ren) common to the parties,
AND
there is proof of timely payment of a previously ordered obligation without an income deduction order
in cases of modification,
AND
_____ there is an agreement by the Obligor to advise the Title IV-D agency, the clerk of court, and the
Obligee of any change in Payor and/or health insurance OR ( ) there is a signed written agreement
providing an alternative arrangement between the Obligor and the Obligee and, at the option of the IV-
D agency, by the IV-D agency in IV-D cases in which there is an assignment of support rights to the state,
reviewed and entered in the record by the court.

3. Bonus/one-time payments. _____ All ______% _____ No income paid in the form of a bonus or
other similar one-time payment, up to the amount of any arrearage or the remaining balance
thereof owed pursuant to this order, shall be forwarded to the Obligee pursuant to the payment
method prescribed above.

4. Other provisions relating to method of temporary payment: ____________________________

SECTION V. TEMPORARY ATTORNEY’S FEES, COSTS, AND SUIT MONEY

1. _____ Petitioner’s _____ Respondent’s request(s) for temporary attorney’s fees, costs, and suit
money is (are) denied because
.

2. _____ The Court finds there is a need for and an ability to pay temporary attorney’s fees, costs,
and suit money. _____ Petitioner _____ Respondent is hereby ordered to pay to the other party
$__________ in temporary attorney’s fees, and $__________ in costs. The Court further finds
that the temporary attorney’s fees awarded are based on the reasonable rate of $__________
per hour and _____reasonable hours. Other provisions relating to temporary attorney fees,
costs, and suit money are as follows:

SECTION VI. OTHER PROVISIONS

Other Provisions:

Florida Supreme Court Approved Family Law Form 12.947(d), Order for Temporary Support and Other Relief With
No Dependent or Minor Child(ren) (03/15)
- 322 -
.

DONE AND ORDERED in __________________________, Florida, on {date} _______________________.

____________________________________________
CIRCUIT JUDGE

I certify that a copy of this {name of document}____________________________________________
was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the parties or entities listed
below on {date}___________________________.

by___________________________________
{Clerk of Court or designee}

Petitioner (or his or her attorney)
Respondent (or his or her attorney)
State Disbursement Unit
Other:

Florida Supreme Court Approved Family Law Form 12.947(d), Order for Temporary Support and Other Relief With
No Dependent or Minor Child(ren) (03/15)
- 323 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY
LAW FORM 12.950(a)
AGREEMENT FOR RELOCATION WITH MINOR CHILD(REN)
(03/15)

When should this form be used?

This form should be used when the parents and every other person entitled to access to,
visitation, or time-sharing with the minor child(ren) are in agreement and are asking the court to
permit the relocation of the child(ren)’s principal residence. “Other Person” means an individual
who is not the parent, but with whom the child resides pursuant to court order, or who has the
right of access to, time-sharing with, or visitation with the child(ren). This form can be used at
any time after either a petition or supplemental petition to relocate has been filed and the
parties reach an agreement; OR can be used when the parties are in agreement and there is an
existing cause of action, judgment, or decree of record pertaining to the child(ren)’s residence
or time-sharing schedule. Either an agreement for relocation or a petition to relocate is
required when:

1. You plan to relocate the child(ren)’s residence more than 50 miles from the child(ren)’s
principal residence at the time of the last order which established or modified either a
Parenting Plan or time-sharing schedule or at the time of filing of the pending action.

2. The court has not already entered an order granting permission to relocate.

3. The relocation will be for a period of 60 consecutive days or more, not including any
absence for purposes of vacation, education, or health care for the child(ren).

4. Your order or final judgment defining custody, primary residence, the Parenting Plan, or
time-sharing was entered before October 1, 2009 and the order does not expressly govern
the relocation of the child(ren); or was entered on or after October 1, 2009, or your case
was pending on October 1, 2009.

5. If the visitation or time-sharing schedule will change due to the relocation, a Parenting
Plan with a time-sharing schedule must be included with the Agreement. Regardless of
whether there is an agreement, the court reserves jurisdiction to modify issues relating to
the minor child(ren).

Instructions for Florida Supreme Court Approved Family Law Form 12.950(a), Agreement for Relocation
with Minor Child(ren) (03/15)
- 324 -
IMPORTANT INFORMATION REGARDING E-FILING

The Florida Rules of Judicial Administration now require that all petitions, pleadings, and
documents be filed electronically except in certain circumstances. Self-represented litigants
may file petitions or other pleadings or documents electronically; however, they are not
required to do so. If you choose to file your pleadings or other documents electronically, you
must do so in accordance with Florida Rule of Judicial Administration 2.525, and you must follow
the procedures of the judicial circuit in which you file. The rules and procedures should be
carefully read and followed.

What should I do next?

For your case to proceed, you must properly notify the court by filing the original of the
Agreement and a Motion for Order Permitting Relocation by Agreement, Florida Supreme
Court Approved Family Law Form, 12.950 (b), with the clerk of the circuit court of one of the
following: the circuit court which has jurisdiction in accordance with the Uniform Child Custody
Jurisdiction and Enforcement Act; the circuit court in the county in which either parent and the
child(ren) reside; or the circuit court in which the original action was adjudicated. If the order
was entered in another state, or if the child(ren) live(s) in another state, you should speak with
an attorney about where to file this form. You should file the original with the clerk of the
circuit court and keep a copy for your records.

If the issue of the child(ren)’s physical residence is already before the court in an ongoing
proceeding or through a judgment issued by the court, the court may enter an order adopting
the Agreement without holding a hearing once both parties have signed it and neither has
requested a hearing. When a hearing is not timely requested, the court shall presume that
relocation is in the best interest of the child(ren) and may adopt the Agreement without holding
a hearing.

If one or more of the parties to the Agreement timely requests a hearing in writing within 10
days after the date the Agreement is filed with the court, then you must notify the other
party(ies) of the hearing by using a Notice of Hearing (General), Florida Supreme Court
Approved Family Law Form 12.923, or other appropriate notice of hearing form. The court will
then enter an order after the hearing.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions for Florida Supreme Court Approved Family Law Form 12.950(a), Agreement for Relocation
with Minor Child(ren) (03/15)
- 325 -
SELF-REPRESENTED LITIGANTS MAY SERVE DOCUMENTS BY E-MAIL; HOWEVER, THEY ARE NOT
REQUIRED TO DO SO. If a self-represented litigant elects to serve and receive documents by e-
mail, the procedures must always be followed once the initial election is made.

To serve and receive documents by e-mail, you must designate your e-mail addresses by using
the Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family
Law Form 12.915, and you must provide your e-mail address on each form on which your
signature appears. Please CAREFULLY read the rules and instructions for: Certificate of Service
(General), Florida Supreme Court Approved Family Law Form 12.914; Designation of Current
Mailing and E-mail Address, Florida Supreme Court Approved Family Law Form 12.915; and
Florida Rule of Judicial Administration 2.516.

Where can I look for more information?
Before proceeding, you should read “General Information for Self-Represented Litigants”
found at the beginning of these forms. The words that are in “bold underline” in these
instructions are defined there. For further information, see chapter 61, Florida Statutes.

If your case involves a modification of any provision relating to child support, you should also
check with the clerk of the circuit court in the county in which you are filing this Agreement for
Relocation to determine if any other forms must be filed.

If the parties agree to a modification of child support, the following forms should be filed with
this Agreement:

 A Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form
12.902(e),
 A completed Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form
12.902(b) or (c).
 A completed Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA)
Affidavit, Florida Supreme Court Approved Family Law Form 12.902(d).

Special notes...
The Agreement for Relocation with Minor Children must contain a Parenting Plan with a time-
sharing schedule. At a minimum, the Parenting Plan must describe in adequate detail:
 How the parties will share and be responsible for the daily tasks associated with the
upbringing of the child(ren),
 The time-sharing schedule that specifies the time that the minor child(ren) will spend
with each parent and every other person entitled to access or time-sharing,
 A designation of who will be responsible for any and all forms of health care, school-
related matters, including the address to be used for school-boundary determination and
registration, and any other activities,
 The methods and technologies that the parents will use to communicate with the
child(ren), and
 Any transportation arrangements related to access or time-sharing.

Instructions for Florida Supreme Court Approved Family Law Form 12.950(a), Agreement for Relocation
with Minor Child(ren) (03/15)
- 326 -
The best interests of the child(ren) is the primary consideration in the Parenting Plan. In creating
the Parenting Plan, all circumstances between the parties, including the parties’ historic
relationship, domestic violence, and other factors must be taken into consideration.
Determination of the best interests of the child(ren) shall be made by evaluating all of the
factors affecting the welfare and interest of the particular minor child(ren) and the
circumstances of the family as listed in s. 61.13(3), Florida Statutes.

This standard form does not include every possible issue that may be relevant to the facts of
your case. The Parenting Plan should be as detailed as possible to address the time-sharing
schedule. Additional provisions should be added to address all of the relevant factors. The
parties should give special consideration to the age and needs of each child.

The Parenting Plan and time-sharing schedule may be set forth in the body of the Agreement for
Relocation with Minor Children or may be attached as a separate document. You may attach a
Relocation/Long-Distance Parenting Plan, Florida Supreme Court Approved Family Law Form
12.995(c), or similar form.

In developing the Parenting Plan, you may wish to consult or review other materials which are
available at your local library, law library or through national and state family organizations.

Nonlawyer. . . Remember, a person who is NOT an attorney is called a nonlawyer. If a
nonlawyer helps you fill out these forms, that person must give you a copy of a Disclosure from
Nonlawyer, Florida Family Law Rules of Procedure Form 12.900(a), before he or she helps you.
A nonlawyer helping you fill out these forms must put his or her name, address, and telephone
number on the bottom of the last page of every form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.950(a), Agreement for Relocation
with Minor Child(ren) (03/15)
- 327 -
IN THE CIRCUIT COURT OF THE _____________________ JUDICIAL CIRCUIT,
IN AND FOR ______________________________ COUNTY, FLORIDA

Case No: __________________
Division: __________________

_________________________________,
Petitioner,
And

_________________________________,
Respondent.

AGREEMENT FOR RELOCATION WITH MINOR CHILD(REN)
_____INCLUDING OR _____ NOT INCLUDING MODIFICATION OF
CHILD SUPPORT

I, {full legal name} ____________________________________, (Petitioner) and I, {full legal
name} _______________________________________, (Respondent) being sworn, certify that
the following information is true:

1. The parties to this action were granted a final judgment of ____ dissolution of marriage
____ paternity on {date} ______________. A copy of the final judgment and any
modification(s) is/are attached.

2. {If Applicable}. The following other person is an individual who is not a parent, but with
whom the child resides pursuant to a court order, or who has the right of access to, time-
sharing with, of visitation with the child(ren)____________________________________.

3. Paragraph(s) ________________ of the ____ final judgment or ____ most recent
modification thereof describes the present custody, visitation, or time-sharing schedule.

4. The dependent or minor child(ren) referred to in this Agreement are:

Name(s) Birth Date(s)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

SECTION I. RELOCATION

A. Since the final judgment or last modification thereof, there has been a substantial

Florida Supreme Court Approved Family Law Form 12.950(a), Agreement for Relocation with Minor
Child(ren) (03/15)
- 328 -
change in circumstances, requiring a modification of the present visitation, Parenting Plan,
or time-sharing schedule. Both parties agree and stipulate to the following terms regarding
modification to allow the ________________________to relocate with the minor child (ren)
and modify the terms regarding visitation or time-sharing, with or without a hearing.

B. The following relocation information is true and correct:
1. The location of the intended new residence, including the state, city, and physical
address, if known, is: ______________________________________________________
________________________________________________________________________
_______________________________________________________________________.

2. The mailing address of the new physical residence, if not the same as the physical
address, is: ______________________________________________________________.

3. The home telephone number of the intended new residence, if known, is:___________.

4. The date of the intended move or proposed relocation is: ________________________.

SECTION II: PARENTAL RESPONSIBILITY AND TIME-SHARING SCHEDULE {Choose only one}

1.____ Parental Responsibility and Time-Sharing shall remain the same as previously set out in
the: ____ Final Judgment of Dissolution, ____ Final Judgment of Paternity or subsequent
____ Other {title of supplemental order or judgment}___________________________
dated _______________________________ and will continue without modification;

2.____ The parties shall comply with the Parenting Plan which is attached and incorporated
herein as Exhibit ____.

3.____ The parties shall comply with the following Parenting Plan and time-sharing schedule:

A. JURISDICTION
The United States is the country of habitual residence of the child(ren).

The State of Florida is the child(ren)’s home state for the purposes of the Uniform Child
Custody Jurisdiction and Enforcement Act.

This Parenting Plan is a child custody determination for the purposes of the Uniform Child
Custody Jurisdiction and Enforcement Act, the International Child Abduction Remedies Act,
42 U.S.C. Sections 11601 et seq., the Parental Kidnapping Prevention Act, and the
Convention on the Civil Aspects of International Child Abduction enacted at the Hague on
October 25, 1980, and for all other state and federal laws.

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Other: _______________________________________________________________.

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B. PARENTAL RESPONSIBILITY AND DECISION MAKING

1. Parental Responsibility {Choose only one}

a._____ Shared Parental Responsibility.
It is in the best interests of the child(ren) that the parents confer and jointly
make all major decisions affecting the welfare of the child(ren). Major decisions
include, but are not limited to, decisions about the child(ren)’s education,
healthcare, and other responsibilities unique to this family.

b._____Shared Parental Responsibility with Decision Making Authority.
It is in the best interests of the child(ren) that the parents confer and attempt to
agree on the major decisions involving the child(ren). If the parents are unable
to agree, the authority for making major decisions regarding the child(ren) shall
be as follows:

Education/Academic decisions ____ Mother ____ Father
Non-emergency health care ____ Mother ____ Father
___________________________ ____ Mother ____ Father
___________________________ ____ Mother ____ Father
___________________________ ____ Mother ____ Father

c._____ Sole Parental Responsibility:
It is in the best interests of the child(ren) that the ____ Mother ____ Father shall
have sole authority to make major decisions for the child(ren.) It is detrimental
to the child(ren) for the parents to share decision making because:
_________________________________________________________________
_________________________________________________________________.

2. Day-to-Day Decisions
Unless otherwise specified in this Parenting Plan, each parent shall make decisions
regarding day-to-day care and control of each child, including the performance of daily
tasks, while the child is with that parent. Regardless of the allocation of decision making
in the Parenting Plan, either parent may make emergency decisions affecting the health
or safety of the child(ren) when the child is residing with that parent. A parent who
makes an emergency decision shall share the decision with the other parent as soon as
reasonably possible.

3. Extracurricular Activities {Choose all that apply}

a._____ Either parent may register the child(ren) and allow them to participate in the
activity of the child(ren)’s choice.

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b._____The parents must mutually agree to all extra-curricular activities.

c._____ The costs of the extra-curricular activities shall be paid by:
Mother ______% Father _______ %

d._____The uniforms and equipment required for the extra-curricular activities shall be
paid by: Mother _______ % Father ________%

e._____Other: _____________________________________________________ .

C. INFORMATION SHARING. Unless Otherwise Indicated or Ordered by the Court:

1. Unless otherwise prohibited by law, both parents shall have access to medical and
school records pertaining to the child(ren) and shall be permitted to independently
consult with any and all professionals involved with the child(ren). The parents shall
cooperate with each other in sharing information related to the health, education, and
welfare of the child(ren) and they shall sign any necessary documentation ensuring that
both parents have access to said records.

2. Each parent shall be responsible for obtaining records and reports directly from the
school and health care providers.

3. Both parents have equal rights to inspect and receive governmental agency and law
enforcement records concerning the child(ren).

4. Both parents shall have equal and independent authority to confer with the child(ren)’s
school, day care, health care providers, and other programs with regard to the
child(ren)’s educational, emotional, and social progress.

5. Both parents shall be listed as “emergency contacts” for the child(ren).

6. Each parent has a continuing responsibility to provide a residential and mailing address,
and contact telephone number(s) to the other parent. Each parent shall notify the other
parent in writing within 24 hours of any changes. Each parent shall notify the court in
writing within seven (7) days of any changes.

7. Other: _________________________________________________________________
_______________________________________________________________________ .

D. SCHEDULING

1. School Calendar
If necessary, on or before ___________ of each year, both parents should obtain a copy
of the school calendars for the next school year. The parents shall discuss the calendars
and the time-sharing schedule so that any differences or questions can be resolved.

Florida Supreme Court Approved Family Law Form 12.950(a), Agreement for Relocation with Minor
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The parents shall follow the school calendar of: {Choose all that apply}
_____ the oldest child
_____ the youngest child
_____ the school calendar for ______________ County
_____ the school calendar for _________________ School

2. Academic Break Definition
When defining academic break periods, the period shall begin at the end of the last
scheduled day of classes before the holiday or break and shall end on the first day of
regularly scheduled classes after the holiday or break.

3. Schedule Changes {Choose all that apply}

a._____ A parent making a request for a schedule change will make the request as soon
as possible, but in any event, except in cases of emergency, no less than
______________ before the change is to occur.

b._____A parent requesting a change of schedule shall be responsible for any additional
child care, or transportation costs caused by the change.

c._____ Other __________________________________________________________.

E. TIME-SHARING SCHEDULE

1. Weekday and Weekend Schedule
The following schedule shall apply beginning on ________________________ with the
_____ Mother _____ Father and continue as follows:

The child(ren) shall spend time with the Mother on the following dates and times:
WEEKENDS: ____ Every ____ Every Other ____ Other (specify): ___________________
From____________________________ to _____________________________________
WEEKDAYS: Specify days ___________________________________________________
From _____________________________ to ___________________________________
OTHER: (Specify) _________________________________________________________
________________________________________________________________________
_______________________________________________________________________ .

The child(ren) shall spend time with the Father on the following dates and times:
WEEKENDS: ____ Every ____ Every Other ____ Other {specify}: ___________________
From____________________________ to _____________________________________
WEEKDAYS: {Specify days} _________________________________________________
From _____________________________ to ___________________________________
OTHER: {specify} _________________________________________________________
_______________________________________________________________________

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_______________________________________________________________________ .

The child(ren) shall spend time with ________________________on the following dates
and times:
WEEKENDS: ____ Every ____ Every Other ____ Other {specify}:____________________
From _______________________________to__________________________________
WEEKDAYS: {Specify days}__________________________________________________
From________________________________to__________________________________
OTHER: {specify} __________________________________________________________
________________________________________________________________________
________________________________________________________________________

Please indicate below if there is a different time-sharing schedule for any child.
Complete a separate Attachment for each child for whom there is a different time-
sharing schedule.

_____ There is a different time-sharing schedule for the following child(ren) in
Attachment _____.

______________________________, and _________________________.
(Name of Child) (Name of Child)

2. Holiday Schedule {Choose only one}

a.____ No holiday time sharing shall apply. The regular time-sharing schedule set forth
above shall apply.

b.____ Holiday time-sharing shall be as the parties agree.

c.____ Holiday time-sharing shall be in accordance with the following schedule. The
holiday schedule will take priority over the regular weekday, weekend, and
summer schedules. Fill in the blanks with Mother or Father to indicate where
the child(ren) will be for the holidays. Provide the beginning and ending times.
If a holiday is not specified as even, odd, or every year with one parent, then the
child(ren) will remain with the parent in accordance with the regular schedule

Holidays Even Years Odd Years Every Year Begin/End Time
Mother’s Day __________ _________ __________ _________________
Father’s Day __________ _________ __________ _________________
President’s Day __________ _________ __________ _________________
Martin Luther King Day _____ _________ __________ _________________
Easter ____ _________ __________ _________________
Passover ____ _________ __________ _________________
Memorial Day Weekend ____ _________ __________ ________________
4th of July ____ _________ __________ _________________
Labor Day Weekend ____ _________ __________ _________________

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Columbus Day Weekend ____ _________ __________ _________________
Halloween ____ _________ __________ _________________
Thanksgiving ____ _________ __________ ________________
Veteran’s Day ____ _________ __________ _________________
Hanukkah ____ _________ __________ _________________
Yom Kippur ____ _________ __________ _________________
Rosh Hashanah ____ __________ __________ _________________
Child(ren)’s Birthdays ____ _________ __________ _________________
___________________________________ __________ _________________

3. Winter Break
A. Winter Break {Choose only one}

1._____The ____Mother ____ Father shall have the child(ren) from the day and
time school is dismissed until December _____ at _____ a.m./p. m in
____odd-numbered years ____ even-numbered years ____ every year.
The other parent will have the children for the second portion of the Winter
Break. The parties shall alternate the arrangement each year.

2._____The ____ Mother ____ Father shall have the child(ren) for the entire Winter
Break during ____ odd-numbered years ____ even-numbered years
____ every year.

3._____Other:
______________________________________________________________
______________________________________________________________
_____________________________________________________________.

B. Specific Winter Holidays
If not addressed above, the specific Winter Holidays such as Christmas, New Year’s
Eve, Hanukkah, Kwanzaa, etc. shall be shared as follows:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________.

4. Spring Break {Choose only one}

a._____ The parents shall follow the regular schedule.

b._____The parents shall alternate the entire Spring Break with the Mother having the
child(ren) during the _____ odd-numbered _____ even-numbered years.

c._____ The _____ Father _____ Mother shall have the child(ren) for the entire Spring
Break every year.

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d._____The Spring Break will be evenly divided. The first half of the Spring Break will go
to the parent whose regularly scheduled weekend falls on the first half and the
second half going to the parent whose weekend falls during the second half.

e._____Other: ___________________________________________________________

5. Summer Break {Choose only one}

a._____ The parents shall follow the regular schedule through the summer.

b._____The _____ Mother _____Father shall have the entire Summer Break from
__________ after school is out until _______________ before school starts.

c._____ The parents shall equally divide the Summer Break. During ____ odd-numbered
years ____ even-numbered years, the _____Mother _____ Father shall have the
child(ren) from ____________after school is out until________________. The
other parent shall have the child(ren) for the second half of the summer break.
The parents shall alternate the first and second halves of Summer Break each
year unless otherwise agreed. During the extended periods of time-sharing, the
other parent shall have the child(ren)_______________________.

d._____Other:_____________________________________________________.

6. Number of Overnights:
Based upon the time-sharing schedule, the Mother has a total of _____ overnights per
year and the Father has a total of _____ overnights per year. Note: The two numbers
must equal 365.

F. TRANSPORTATION AND EXCHANGE OF CHILD(REN)

Both parents shall have the child(ren) ready on time with sufficient clothing packed and
ready at the agreed upon time of exchange. All necessary information and medicines will
accompany the child(ren).

The parties shall exchange travel information and finalize travel plans at least _____ days in
advance of the date of travel. Except in cases of emergency, any parent requesting a change
of travel plans after the date of finalization shall be solely responsible for any additional
costs.

1. Automobile Transportation and Exchange
If a parent is more than _____ minutes late without contacting the other parent to make
other arrangements, the parent with the child(ren) may proceed with other plans and

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activities. {Choose only one}

a._____ The _____ Mother _____ Father shall provide all transportation.

b._____The _____ Mother _____ Father shall pick up the child(ren) at the beginning of
the visit and the other parent shall pick up the child(ren) at the end of the visit.
The exchange shall take place:

c._____ At the parents’ homes unless otherwise agreed

d._____At the following location unless the parties agree in advance to a different
place________________________________________________________.
e._____The parents shall meet at the following central location:
______________________________________________________________.

f._____ Other: _________________________________________________________.

2. Airplane and Other Public Transportation and Exchange
Airline regulations govern the age at which a child may fly unescorted. An older child or
children may fly under such regulations as each airline may establish.

Airline reservations should be made well in advance, and preferably non-stop.

All flight information shall be sent to the other party(ies) at least _____days in advance
of the flight by the party purchasing the tickets.

If the child(ren) are flying accompanied by a party, the parent picking up the child(ren)
shall exchange the child(ren) with the other parent at ________________________and
the parent returning the child(ren) shall exchange the child(ren)
at______________________________________________.

If the exchange is to be made at the airport, the party flying in to pick up or drop off the
child(ren) from/to the airport must notify the other party of any flight delays.

Unless otherwise agreed in advance, if the child(ren) are flying unaccompanied, the
parent taking the child(ren) to the airport must call the other parent immediately upon
departure to notify the other parent that the child(ren) is/are arriving, and the parent
who meets the child(ren) must immediately notify the other parent upon the
child(ren)’s arrival. {Indicate all that apply}

a._____ Until a child reaches the age of _____, the parties agree that the child(ren) shall
take a direct flight and/or fly accompanied by__________________________.

b._____Once a child reaches the age of ____ the child shall be permitted to fly
accompanied by an airline employee.

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c._____ Once a child reached the age of ____ the child shall be permitted to fly
unescorted.

d._____Other: ___________________________________________________________.

3. Costs of Airline and Other Public Transportation
The parents shall work together to purchase the most convenient and least expensive
tickets.

Unless otherwise agreed or in the case of an unavoidable emergency, any costs incurred
by a missed travel connection shall be the sole responsibility of the parent who failed to
timely deliver the child(ren) to the missed connection.{Indicate all that apply}

a._____ Transportation costs are included in the Child Support Worksheets and/or the
Order for Child Support and should not be included here.

b._____The Mother shall pay ______% and the Father shall pay ______ % of the
transportation costs.

c._____ The Mother shall pay ______% and the Father shall pay _____% of the
transportation costs for an adult to accompany the child(ren) during travel.

d._____If the parents are sharing travel costs, the non-purchasing parent shall
reimburse the other parent within ____ days of receipt of documentation
establishing the travel costs.

e._____Other: __________________________________________________________.

4. Foreign and Out-Of-State Travel {Indicate all that apply}

a._____ Either parent may travel within the United States with the child(ren) during
his/her time-sharing. The parent traveling with the child(ren) shall give the
other parent at least _____ days written notice before traveling out of state
unless there is an emergency, and shall provide the other parent with a detailed
itinerary, including locations and telephone numbers where the child(ren) and
parent can be reached at least _____ days prior to traveling.

b._____Either parent may travel out of the country with the child(ren) during his/her
time-sharing. At least _____ days prior to traveling, the parent shall provide a
detailed itinerary, including locations, and telephone numbers where the
child(ren) and parent may be reached during the trip. Each parent agrees to
provide whatever documentation is necessary for the other parent to take the
child(ren) out of the country.

c._____ If a parent wishes to travel out of the country with the child(ren), he/she shall

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provide the following security for the return of the child(ren) _______________
_________________________________________________________________
_________________________________________________________________.

d._____Other ___________________________________________________________.

5. Other travel and exchange arrangements:
____________________________________________________________________
____
________________________________________________________________________

G. EDUCATION

1. School designation. For purposes of school boundary determination and registration,
the _____ Mother’s _____ Father’s address shall be designated.

2. {If Applicable} The following provisions are made regarding private or home schooling:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________ .

3. Other. __________________________________________________________________
________________________________________________________________________
_______________________________________________________________________

H. DESIGNATION FOR OTHER LEGAL PURPOSES

The child(ren) named in this Relocation Agreement are scheduled to reside the majority of
the time with the _____ Mother _____ Father. This majority designation is SOLELY for
purposes of all other state and federal laws which require such a designation. This
designation does not affect either parent’s rights or responsibilities under this Relocation
Agreement.

I. COMMUNICATION

1. Between Parents
All communications regarding the child(ren) shall be between the parents. The parents
shall not use the child(ren) as messengers to convey information, ask questions, or set
up schedule changes.

The parents shall communicate with each other by: {Indicate all that apply}
a._____ in person
b._____by telephone
c._____ by letter
d._____by e-mail

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e._____Other:_____________________________________________________.

2. Between Parent and Child(ren)

Both parents shall keep contact information current. Telephone or other electronic
communication between the child(ren) and the other parent shall not be monitored by
or interrupted by the other parent. “Electronic communication” includes telephones,
electronic mail or e-mail, webcams, video-conferencing equipment and software or
other wired or wireless technologies or other means of communication to supplement
face to face contact.

The child(ren) may have _____ telephone ____ e-mail _____ other electronic
communication in the form of ___________________________________ with the other
parent: (Choose only one)
a.____ Anytime
b.____ Every day during the hours of _________________ to _____________________.
c.____ On the following days_______________________________________________
during the hours of ________________________ to ______________________.
d.____ Other: ___________________________________________________________.

3. Costs of Electronic Communication shall be addressed as follows:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

J. CHANGES OR MODIFICATIONS OF THE PARENTING PLAN

Temporary changes may be made informally without a written document. When the
parents do not agree, the Parenting Plan remains in effect until further order of the court.

Any substantial changes to the Parenting Plan must be sought through the filing of a
supplemental petition for modification.

K. DISPUTES OR CONFLICT RESOLUTION

Parents shall attempt to cooperatively resolve any disputes which may arise over the terms
of the Parenting Plan. The parents may wish to use mediation or other dispute resolution
methods and assistance, such as Parenting Coordinators and Parenting Counselors, before
filing a court action.

SECTION III: CHILD SUPPORT AND INSURANCE

A. If the requested modification is granted, the parties:
1.____ agree that child support should be modified, consistent with the modification of the
time-sharing schedule
2.____ agree that child support will NOT be modified.

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B. The ____ Mother ____ Father (hereinafter “Obligor”) will pay child support, under
Florida’s child support guidelines, section 61.30, Florida Statutes, to the other parent. The
Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e),
is completed and attached.

This parent shall be obligated to pay child support at the rate of $____________, per month
for the ______children {number of parties’ minor or dependent children} beginning {month,
day, year} ______________________ and terminating _______________________{month,
day, year}. Child support shall be paid in the amount of $______________ per
____________{week, month, other}, which is consistent with the Obligor’s current payroll
cycle.

Upon the termination of the obligation of child support for one of the parties’ children, child
support in the amount of $________________ for the remaining________ children {total
number of remaining children} shall be paid beginning ____________________ {month, day,
year} and terminating ______________________ {month, day, year}. This child support shall
be paid in the amount of $________________ per _____________ {week, month, other}
consistent with the Obligor’s current payroll cycle.

The Obligor shall pay child support until all the minor or dependent children: reach the age
of 18, become emancipated, marry, die, joins the armed services; or become self-
supporting; or until further order of the court or agreement of the parties. The child support
obligation shall continue beyond the age of 18, and until high school graduation for any child
who is: dependent in fact; between the ages of 18 and 19; and is still in high school,
performing in good faith with a reasonable expectation of graduation before the age of 19.

If the child support amount above deviates from the guidelines by 5% or more, explain the
reason(s) here:
__________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________.

C. Child Support Arrearage. There currently is a child support arrearage of $
______________
for retroactive child support and/or $______________ for previously ordered unpaid child
support. The total of $ ______________ in child support arrearage shall be repaid at the
rate of $ ______________every ____ week ____ other week ____ month, beginning
{date} __________, until paid in full including statutory interest.

D. Health Insurance.
1.____The ____ Mother ____ Father will maintain health insurance for the parties’ minor

Florida Supreme Court Approved Family Law Form 12.950(a), Agreement for Relocation with Minor
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child(ren). The party providing health insurance will provide insurance cards to the other
party showing coverage.

2.____ Health insurance is either not reasonable in cost or accessible to the child(ren) at this
time. Any uninsured/ unreimbursed medical costs for the minor child(ren) shall be assessed
as follows:
a.____Shared equally by both parents.
b.____Prorated according to the child support guideline percentages.
c.____Other {explain}: ______________________________________________________

As to these uninsured/unreimbursed medical expenses, the party who incurs the expense
shall submit a request for reimbursement to the other party within 30 days, and the other
party, within 30 days of receipt, shall submit the applicable reimbursement for that
expense, according to the schedule of reimbursement set out in this paragraph.

E. Dental Insurance.
1.____The ____ Mother ____ Father will maintain dental insurance for the parties’ minor
child(ren). The party providing dental insurance will provide insurance cards to the other
party showing coverage.

2.____ Dental insurance is either not reasonable in cost or available to the children at this
time. Any uninsured/unreimbursed dental costs for the minor child(ren) shall be assessed
as follows:
d. _____Shared equally by both parents.
e. _____Prorated according to the child support guideline percentages.
f. _____Other {explain}:
___________________________________________________

As to these uninsured/unreimbursed dental expenses, the party who incurs the expense
shall submit a request for reimbursement to the other party within 30 days, and the other
party, within 30 days of receipt, shall submit the applicable reimbursement for that
expense, according to the schedule of reimbursement set out in this paragraph.

F. Life Insurance.
The ____ Mother ____ Father shall be required to maintain life insurance coverage for the
benefit of the parties’ minor child(ren) in the amount of $ _________________ until the
youngest child turns 18, becomes emancipated, marries, joins the armed services, or dies.

SECTION IV: OTHER
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

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______________________________________________________________________________
________________________________________________________________________

Florida Supreme Court Approved Family Law Form 12.950(a), Agreement for Relocation with Minor
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I certify that I have been open and honest in entering into this relocation agreement. I am
satisfied with this agreement and intend to be bound by it.

Dated: ______________________ _______________________________________
Signature of Mother

Printed Name: ___________________________
Address: _______________________________
City, State, Zip: __________________________
Telephone Number: ______________________
Fax Number: ___________________________
Designated E-mail Address(es):____________
___________________________________

STATE OF FLORIDA
COUNTY OF ____________________

Sworn to or affirmed and signed before me on __________ by ___________________________.

_______________________________________
NOTARY PUBLIC or DEPUTY CLERK

_______________________________________
{Print, type, or stamp commissioned name of
notary or deputy clerk.}
____ Personally known
____ Produced identification
____ Type of identification produced ________________________________

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I certify that I have been open and honest in entering into this relocation agreement. I am
satisfied with this agreement and intend to be bound by it.

Dated: ______________________ _______________________________________
Signature of Father

Printed Name: ___________________________
Address: _______________________________
City, State, Zip: __________________________
Telephone Number: ______________________
Fax Number: ____________________________
Designated E-mail Address(es):____________
____________________________________

STATE OF FLORIDA
COUNTY OF ____________________

Sworn to or affirmed and signed before me on __________ by ___________________________.

_______________________________________
NOTARY PUBLIC or DEPUTY CLERK

_______________________________________
[Print, type, or stamp commissioned name of
notary or deputy clerk.]

____ Personally known
____ Produced identification
____ Type of identification produced ________________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS
BELOW: [fill in all blanks]
This form was prepared for the: {choose only one} _______Mother ______Father.
This form was completed with the assistance of:
{name of individual} _________________________________________________________ ,
{name of business} __________________________________________________________ ,
{address} _____________________________________________________________________,
{city} ____________, {state}___, {zip code} _________,{telephone number} ______________ .

Florida Supreme Court Approved Family Law Form 12.950(a), Agreement for Relocation with Minor
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INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.950(b)
MOTION FOR ORDER PERMITTING RELOCATION BY AGREEMENT
(03/15)

When should this form be used?

 One of the parents or a person entitled to access to or time-sharing with the children wishes to
relocate the child(ren) to a residence more than 50 miles from the child(ren)’s principal place of
residence at the time of the last order establishing or modifying time-sharing or at time of filing of
the pending action.

 There is an existing cause of action, judgment, or decree of record pertaining to the child(ren)’s
residence or time sharing schedule.

 The parents and every other person entitled to access to or time-sharing with the children have
signed a written agreement, Agreement for Relocation with Minor Child(ren), Florida Supreme
Court Approved Family Law Form, 12.950(a), or similar form which:
1. Reflects the consent to the relocation;
2. Defines an access or time-sharing schedule for the non-relocating parent and any other persons
who are entitled to access or time-sharing; and
3. Describes, if necessary, any transportation arrangements related to access or time-sharing.

 Your order regarding custody, primary residence, the parenting plan, time-sharing, or access to
or with the child(ren) was entered before October 1, 2009 and the order does not expressly govern
the relocation of the child(ren); was entered on or after October 1, 2009; or your case was pending
on October 1, 2009.

This form should be typed or printed in black ink. You must fill in all sections of the form. If you are an
“other person” entitled to access, visitation, or time-sharing with the child(ren), substitute your name
for Mother or Father in the form. After completing the form, you should sign the form before a notary
public or deputy clerk. You should file the form in the county where the original order or judgment was
entered. If the order or judgment was entered in another state, or if the child(ren) live(s) in another
state, you should speak with an attorney about where to file this form.

Instructions for Motion for Order Permitting Relocation by Agreement, Florida Supreme Court Approved Family
Law Form 12.950(b) (03/15)
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IMPORTANT INFORMATION REGARDING E-FILING

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

What should I do next?
After completing this form, you should file the original with the clerk of the circuit court where there is
an existing cause of action, judgment, or decree of record pertaining to the child(ren)’s residence or
time-sharing schedule and keep a copy for your records. The original Agreement for Relocation with
Minor Child(ren) should be attached to Motion or filed with the clerk of the circuit court at the same
time.

If both parties agree, the court may ratify the Agreement without the necessity of an evidentiary
hearing. You should check with the clerk, family law intake staff, or judicial assistant for the proper way
to submit the Motion and a proposed Final Judgment/Supplemental Final Judgment Granting
Relocation, Florida Supreme Court Approved Family Law Form 12.950(i), to the judge. If one or more of
the parties to the Agreement timely requests a hearing in writing within 10 days after the date the
Agreement is filed with the court, then you must notify the other party(ies) of the hearing by using a
Notice of Hearing (General), Florida Supreme Court Approved Family Law Form 12.923, or other
appropriate notice of hearing form. The court will then enter an order after hearing. If a hearing is not
timely requested, the court shall presume that relocation is in the best interest of the child(ren) and may

Instructions for Motion for Order Permitting Relocation by Agreement, Florida Supreme Court Approved Family
Law Form 12.950(b) (03/15)
- 347 -
ratify the Agreement without an evidentiary hearing.

Where can I look for more information?

If your case involved a modification of any provision relating to child support, you should also check with
the clerk of the circuit court in the county in which you are filing the Motion for Order Permitting
Relocation with Minor Child(ren) and Agreement for Relocation with Minor Child(ren) to determine if
any other forms must be filed.

Nonlawyer... Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps
you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida
Family Law Rules of Procedure Former 12.900(a), before he or she helps you. A nonlawyer helping you
fill out these forms must put his or her name, address, and telephone number on the bottom of the last
page of every form he or she helps you complete.

Instructions for Motion for Order Permitting Relocation by Agreement, Florida Supreme Court Approved Family
Law Form 12.950(b) (03/15)
- 348 -
IN THE CIRCUIT COURT OF THE _____________________ JUDICIAL CIRCUIT,
IN AND FOR ______________________________ COUNTY, FLORIDA

Case No: ________________________
Division: ________________________

_________________________________,
Petitioner,
And

_________________________________,
Respondent.

MOTION FOR ORDER PERMITTING RELOCATION WITH AGREEMENT

We, ______________________________________________ Father, {full legal name}
__________________________________________________, Mother, {full legal name} and/or
________________________________ {full legal name} of Other Person entitled to Access or Time-
Sharing with child(ren), being sworn, certify that the following information is true: {fill in all blanks}

1. We are asking the Court to permit relocation of the minor child(ren) to a residence at least 50 miles
from the child(ren)’s principal place of residence at the time of entry of the last order establishing or
modifying time-sharing, or at the time of filing of the pending action.

2. There is an existing cause of action, judgment, decree of record pertaining the child(ren)’s residence
or time-sharing schedule.

3. WE CONSENT TO THE RELOCATION OF THE MINOR CHILD(REN) to the following address:
_________________________________________________________________________________.

4. The dependent or minor child(ren) is (are):
Name(s) Birth Date(s)
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

5. Agreement. A written Agreement for Relocation with Minor Child(ren), Florida Supreme Court
Approved Family Law Form 12.950(a) or similar form, is filed with this motion which reflects
consent to the relocation; defines an access or time-sharing schedule for the nonrelocating parent
and any other persons who are entitled to access or time-sharing; and describes, if necessary, any
transportation arrangements related to access or time-sharing.

6. The specific reasons for the proposed relocation of the child(ren) are:_________________________
__________________________________________________________________________________

Motion for Order Permitting Relocation by Agreement, Florida Supreme Court Approved Family Law Form
12.950(b) (03/15)
- 349 -
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Attach additional sheets if necessary.

7. This modification is in the best interests of the child (ren) because: {explain} ___________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

8. Hearing. We seek ratification of the agreement by court order: {choose only one}
a.____ With hearing
b.____ Without hearing

9. A completed Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida
Supreme Court Approved Family Law Form 12.902(d), is filed with this Agreement.

10. If not previously filed in this case, a completed Notice of Social Security Number, Florida Supreme
Court Approved Family Law Form 12.902(j), is filed with this Agreement.

Motion for Order Permitting Relocation by Agreement, Florida Supreme Court Approved Family Law Form
12.950(b) (03/15)
- 350 -
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
motion and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.

Dated: ______________________ _______________________________________
Signature of PETITIONER

Printed Name: ___________________________
Address: _______________________________
City, State, Zip:___________________________
Telephone Number: _________________________
Fax Number:_______________________________
Designated E-mail Address(es):________________
________________________________________

STATE OF FLORIDA
COUNTY OF ____________________

Sworn to or affirmed and signed before me on __________ by ___________________________.

_______________________________________
NOTARY PUBLIC or DEPUTY CLERK

_______________________________________
[Print, type, or stamp commissioned name of notary or
deputy clerk.]
____ Personally known
____ Produced identification
____ Type of identification produced ________________________________

Motion for Order Permitting Relocation by Agreement, Florida Supreme Court Approved Family Law Form
12.950(b) (03/15)
- 351 -
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
motion and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.

Dated: ______________________ _______________________________________
Signature of RESPONDENT

Printed Name: ___________________________
Address: _______________________________
City, State, Zip:___________________________
Telephone Number: ______________________
Fax Number:____________________________
Designated E-mail Address(es)________________
_________________________________________

STATE OF FLORIDA
COUNTY OF ____________________

Sworn to or affirmed and signed before me on __________ by ___________________________.

_______________________________________
NOTARY PUBLIC or DEPUTY CLERK

_______________________________________
[Print, type, or stamp commissioned name of notary or
deputy clerk.]

_____ Personally known
_____ Produced identification
_____ Type of identification produced ________________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ____Petitioner ____Respondent
This form was completed with the assistance of:
{name of individual__________________________________________________________________ ,
{name of business} ____________________________________________________________________,
{address} ________________________________________________________________ ,
{city} _______________,{state}____, {zip code} __________,{telephone number} __________________.

Motion for Order Permitting Relocation by Agreement, Florida Supreme Court Approved Family Law Form
12.950(b) (03/15)
- 352 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.950(c),
PETITION FOR DISSOLUTION OF MARRIAGE WITH DEPENDENT OR
MINOR CHILD(REN) AND RELOCATION (03/15)

When should this form be used?

This form should be used when a husband or wife is filing for dissolution of marriage, there are
dependent or minor children and pursuant to Section 61.13001, Florida Statutes:

1. You plan to relocate your residence more than 50 miles from the principal place of residence
you have at the time of filing this petition; and

2. The change of location is for at least 60 consecutive days, not including a temporary absence
from your principal place of residence for purposes of vacation, education or the provision of
health care for the minor child(ren).

You and/or your spouse must have lived in Florida for at least 6 months before filing for dissolution of
marriage in Florida.

IMPORTANT INFORMATION REGARDING E-FILING

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

SELF-REPRESENTED LITIGANTS MAY SERVE DOCUMENTS BY E-MAIL; HOWEVER, THEY ARE NOT
REQUIRED TO DO SO. If a self-represented litigant elects to serve and receive documents by e-mail, the

Instructions for Florida Supreme Court Approved Family Law Form 12.950(c) Petition for Dissolution of Marriage
with Dependent or Minor Child(ren) and Relocation (03/15)
- 353 -
procedures must always be followed once the initial election is made.

What should I do next?

For your case to proceed, you must properly notify your spouse and every other person entitled to
access or time-sharing with the child(ren) of the petition. “Other Person” means an individual who is
not the parent but with whom the child resides pursuant to court order, or who has the right of access
to, time-sharing with, or visitation with the child(ren). If you know where he or she lives, you should use
personal service. If you absolutely do not know where he or she lives, you may use constructive
service. You may also be able to use constructive service if your spouse or the other person resides in
another state or country. However, if constructive service is used, other than granting a divorce, the
court may only grant limited relief. For more information on constructive service, see Notice of Action
for Dissolution of Marriage, Florida Supreme Court Approved Family Law Form 12.913(a), and Affidavit
of Diligent Search and Inquiry, Florida Family Law Rules of Procedure Form 12.913(b). If your spouse is
in the military service of the United States, additional steps for service may be required. See, for
example, Memorandum for Certificate of Military Service, Florida Supreme Court Approved Family Law
Form 12.912(a). In sum, the law regarding constructive service and service on an individual in the
military service is very complex and you may wish to consult an attorney regarding these issues.

If personal service is used, the respondent has 20 days to answer after being served with your petition.
Your case will then generally proceed in one of the following three ways:

Instructions for Florida Supreme Court Approved Family Law Form 12.950(c) Petition for Dissolution of Marriage
with Dependent or Minor Child(ren) and Relocation (03/15)
- 354 -
mandatory disclosure and filed all of the required papers. Some circuits may require the completion of
mediation before a final hearing may be set. You should contact the clerk, family law intake staff, or
judicial assistant for instructions on how to set your case for trial (final hearing). If your spouse files an
answer and counterpetition, you should answer the counterpetition within 20 days using an Answer to
Counterpetition, Florida Supreme Court Approved Family Law Form 12.903(d).

Where can I look for more information?

Special notes...

With this form, you must also file the following:

 Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida Supreme
Court Approved Family Law Form 12.902(d).
 Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e), if
you are asking that child support be ordered in the final judgment. (If you do not know your
spouse’s income, you may file this worksheet after his or her financial affidavit has been served on
you.)
 Affidavit of Corroborating Witness, Florida Supreme Court Approved Family Law Form 12.902(i)
OR photocopy of current Florida driver’s license, Florida identification card, or voter’s registration
card (issue date of copied document must be at least six months before date case is actually filed
with the clerk of the circuit court).
 Marital Settlement Agreement for Dissolution of Marriage with Dependent or Minor
Child(ren), Florida Supreme Court Approved Family Law Form 12.902(f)(1), if you and your spouse
have reached an agreement on any or all of the issues.
 Notice of Social Security Number, Florida Supreme Court Approved Family Law Form 12.902(j).
 Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or (c).
(This must be filed with the petition if the petitioner seeks to establish child support. Otherwise, it
must be filed within 45 days of service of the petition on the respondent.)

Instructions for Florida Supreme Court Approved Family Law Form 12.950(c) Petition for Dissolution of Marriage
with Dependent or Minor Child(ren) and Relocation (03/15)
- 355 -
 Certificate of Compliance with Mandatory Disclosure, Florida Family Law Rules of Procedure
Form 12.932. (This must be filed within 45 days of service of the petition on the respondent, if not
filed at the time of the petition, unless you and your spouse have agreed not to exchange these
documents.)
 Parenting Plan, Florida Supreme Court Approved Family Law Form 12.995(a), Safety-Focused
Parenting Plan, Form 12.995(b), or Relocation/Long-Distance Parenting Plan, Form 12.995(c). If the
parents have reached an agreement, a signed and notarized Parenting Plan should be attached. If
the parents have not reached an agreement, a proposed Parenting Plan may be filed.

Updating Information. A parent or other person seeking to relocate has a continuing duty to provide
current and updated information required by the relocation statute when that information becomes
known.

Parenting Plan and Time-Sharing. If you and your spouse are unable to agree on parenting
arrangements and a time-sharing schedule, a judge will decide for you as part of establishing a Parenting
Plan. The judge will decide the parenting arrangements and time-sharing based on the child(ren)’s best
interests. Regardless of whether there is an agreement, the court reserves jurisdiction to modify issues
relating to the minor child(ren).

 Shared Parental Responsibility
 Sole Parental Responsibility
 Supervised Time-Sharing
 No contact
 Parenting Plan
 Parenting Plan Recommendation
 Time-Sharing Schedule

Instructions for Florida Supreme Court Approved Family Law Form 12.950(c) Petition for Dissolution of Marriage
with Dependent or Minor Child(ren) and Relocation (03/15)
- 356 -
both parents. You must file a Family Law Financial Affidavit, Florida Family Law Rules of Procedure
Form 12.902(b) or (c), and your spouse will be required to do the same. From your financial affidavits,
you should be able to calculate the amount of child support that should be paid using the Child Support
Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e). Because the child
support guidelines take several factors into consideration, change over time, and vary from state to
state, your child support obligation may be more or less than that of other people in seemingly similar
situations.

Alimony. Alimony may be awarded to a spouse if the judge finds that he or she needs it and that the
other spouse has the ability to pay it. If you want alimony, you must request it in writing in the original
petition or counterpetition. If you do not request alimony in writing before the final hearing, it is
waived (you may not request it later). You may request either permanent alimony, bridge-the-gap
alimony, durational alimony, lump sum alimony, or rehabilitative alimony.

Marital/Nonmarital Assets and Liabilities. Florida law requires an equitable distribution of marital
assets and marital liabilities. “Equitable” does not necessarily mean “equal.” Many factors, including
child support, time-sharing, and alimony awards, may lead the court to make an unequal (but still
equitable) distribution of assets and liabilities. Nonmarital assets and nonmarital liabilities are those
assets and liabilities which the parties agree or the court determines belong to, or are the responsibility
of, only one of the parties. If the parties agree or the court finds an asset or liability to be nonmarital,
the judge will not consider it when distributing marital assets and liabilities.

Temporary Relief. If you need temporary relief regarding temporary use of assets, temporary
responsibility for liabilities, parental responsibility, relocation and time-sharing with child(ren),
temporary child support, or temporary alimony, you may file a Motion for Temporary Support and
Time-Sharing with Dependent or Minor Child(ren), Florida Supreme Court Approved Family Law Form
12.947(a) and a Motion for Temporary Relocation, Florida Supreme Court Approved Family Law From
12.950(e). For more information, see the instructions for those forms.

Marital Settlement Agreement. If you and your spouse are able to reach an agreement on any or all of
the issues, you should file a Marital Settlement Agreement for Dissolution of Marriage with Dependent
or Minor Child(ren), Florida Supreme Court Approved Family Law Form 12.902(f)(1). Both of you must
sign this agreement before a notary public or deputy clerk. Any issues on which you are unable to
agree will be considered contested and settled by the judge at the final hearing.

Parenting Plan. In all cases involving minor or dependent child(ren), a Parenting Plan shall be approved
or established by the court. As you are seeking to relocate, the Parenting Plan must include a post-
relocation schedule for access and time-sharing together with the necessary transportation
arrangements. If you and your spouse have reached an agreement, you should file a Parenting Plan,
Florida Supreme Court Approved Family Law Form 12.995(a), a Safety-Focused Parenting Plan, Florida
Supreme Court Approved Family Law Form 12.995(b), or a Relocation/Long-Distance Parenting Plan,
Florida Supreme Court Approved Family Law Form 12.995(c), which addresses the time-sharing schedule
for the child(ren). If you have not reached an agreement, a proposed Parenting Plan may be filed. If the
parties are unable to agree, a Parenting Plan will be established by the court.

Instructions for Florida Supreme Court Approved Family Law Form 12.950(c) Petition for Dissolution of Marriage
with Dependent or Minor Child(ren) and Relocation (03/15)
- 357 -
Final Judgment Form. These family law forms contain a Final Judgment of Dissolution of Marriage
with Dependent or Minor Child(ren), Florida Supreme Court Approved Family Law Form 12.990(c)(1),
which the judge may use if your case is contested. If you and your spouse reach an agreement on all of
the issues, the judge may use a Final Judgment of Dissolution of Marriage with Dependent or Minor
Child(ren) (Uncontested), Florida Supreme Court Approved Family Law Form 12.990(b)(1). You should
check with the clerk, family law intake staff, or judicial assistant to see if you need to bring a final
judgment with you to the hearing. If so, you should type or print the heading, including the circuit,
county, case number, division, and the parties’ names, and leave the rest blank for the judge to
complete at your hearing or trial.

Instructions for Florida Supreme Court Approved Family Law Form 12.950(c) Petition for Dissolution of Marriage
with Dependent or Minor Child(ren) and Relocation (03/15)
- 358 -
IN THE CIRCUIT COURT OF THE _____________________ JUDICIAL CIRCUIT,
IN AND FOR ______________________________ COUNTY, FLORIDA

Case No: ________________________
Division: ________________________

________________________________________,
Husband,
And

_______________________________________,
Wife.

PETITION FOR DISSOLUTION OF MARRIAGE
WITH DEPENDENT OR MINOR CHILD(REN) AND RELOCATION

I, {full legal name} , the
{Choose only one} ____ Husband ____ Wife, being sworn, certify that the following statements are true:

5. JURISDICTION/RESIDENCE
_____ Husband _____ Wife _____ Both Spouses has/have lived in Florida for at least six (6) months
before the filing of this Petition for Dissolution of Marriage.
6. The husband {Choose only one} _____ is _____ is not a member of the military service.
The wife {Choose only one} _____ is _____ is not a member of the military service.
7. MARRIAGE HISTORY
Date of marriage: {month, day, year}________________________________________________.
Place of marriage: {city, county, state}_______________________________________________.
Date of separation: {month, day, year}_____________________________________ (Please indicate
if approximate).
8. DEPENDENT OR MINOR CHILD(REN)
{Indicate all that apply}
c. ____ The wife is pregnant. Baby is due on: {date}
______________________________________
d. ____ The minor (under 18) child(ren) common to both parties are:

Name(s) Birth Date(s)
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Florida Supreme Court Approved Family Law Form 12.950(c), Petition for Dissolution of Marriage with Dependent
or Minor Child(ren) and Relocation (03/15)
- 359 -
e. _____The minor child(ren) born or conceived during the marriage who are not common to
both parties are:
Name(s) Birth Date(s)
______________________________________________________________________________
______________________________________________________________________________

The birth father(s) of the above minor child(ren) is/are {name(s) and address(es)} ___________
______________________________________________________________________________
______________________________________________________________________________

f. _____ The child(ren) common to both parties who are 18 or older but who are dependent
upon the parties due to a mental or physical disability are:
Name(s) Birth Date(s)
______________________________________________________________________________
______________________________________________________________________________

9. A completed Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form
12.902(b) or (c) {Choose only one}____ has been filed or ____ will be filed.

10. A completed Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit,
Florida Supreme Court Approved Family Law Form 12.902(d), is filed with this petition. (You must
complete and attach this form in a dissolution of marriage with minor child(ren)).

11. A completed Notice of Social Security Number, Florida Supreme Court Approved Family Law
Form 12.902(j), is filed with this petition.

12. This petition for dissolution of marriage should be granted because:
{Choose only one}
c. _____ The marriage is irretrievably broken.
d. _____ One of the parties has been adjudged mentally incapacitated for a period of 3 years
prior to the filing of this petition. A copy of the Judgment of Incapacity is attached to this
Petition.

SECTION I. MARITAL ASSETS AND LIABILITIES
{Choose only one}
3. _____ There are no marital assets or liabilities.

4. _____ There are marital assets or liabilities. All marital and nonmarital assets and liabilities are
(or will be) listed in the financial affidavits, Florida Family Law Rules of Procedure Form 12.902(b) or
(c), to be filed in this case.
{Choose all that apply}
a. _____ All marital assets and liabilities have been divided by a written agreement between the
parties, which is attached, to be incorporated into the final judgment of dissolution of marriage.
(The parties may use Marital Settlement Agreement for Dissolution of Marriage with Dependent

Florida Supreme Court Approved Family Law Form 12.950(c), Petition for Dissolution of Marriage with Dependent
or Minor Child(ren) and Relocation (03/15)
- 360 -
or Minor Child(ren), Florida Supreme Court Approved Family Law Form 12.902(f)(1)).
b. _____ The Court should determine how the assets and liabilities of this marriage are to be
distributed, under section 61.075, Florida Statutes.
c. _____Husband _______Wife should be awarded an interest in the other spouse’s property
because: _____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ .

SECTION II. SPOUSAL SUPPORT (ALIMONY)
{Choose only one}
1. _____ Husband _____Wife forever gives up his/her right to spousal support (alimony) from
the other spouse.

2. _____ Husband _____Wife requests that the Court order the other spouse to pay the following
spousal support (alimony) and claims that he or she has a need for the support that he or she is
requesting and that the other spouse has the ability to pay that support. Spousal support
(alimony) is requested in the amount of $ ________ every _____ week _____ other week
_____month, beginning {date} _____________________ and continuing until {date or event}
_______________________________________________________________ .

Explain why the Court should order _____Husband _____Wife to pay and any specific request(s) for
type of alimony (temporary, permanent, bridge-the-gap, durational, rehabilitative, and/or lump
sum): ________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________ .

{Indicate if applicable} _____ Husband _____Wife requests life insurance on the other spouse’s life,
provided by that spouse, to secure such support.

SECTION III. RELOCATION

1. The ____ Mother ____ Father seeks to relocate his/her residence to a place more than 50 miles
from his/her place of residence at the time of filing of the Petition. The change of location is for a
period of at least consecutive 60 days not including a temporary absence from the principal
residence for purposes of vacation, education, or the provision of health care for the child(ren).

2. { If applicable} The following other person is an individual who is not a parent but with whom
the child resides pursuant to a court order, or who has the right of access to, time-sharing with, or
visitation with the child(ren)__________________________________________________________.

3. Pursuant to Section 61.13001(3), Florida Statutes, the following information is provided:

a. The location of the intended new residence, including the state, city, and physical address, if

Florida Supreme Court Approved Family Law Form 12.950(c), Petition for Dissolution of Marriage with Dependent
or Minor Child(ren) and Relocation (03/15)
- 361 -
known, is: ___________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

b. The mailing address of the new physical residence, if not the same as the physical address, is:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

c. The home telephone number of the intended new residence, if known, is: _________________.

d. The date of the intended move or proposed relocation is: ______________________________.

e. The specific reasons for the proposed relocation are:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.
Attach additional sheets, if necessary.

f. One of the reasons for the proposed relocation is a job
_____ Yes _____ No. A copy of the written job offer is attached to this Petition.

4. The relocation and time-sharing have been agreed to by the parties. {Choose only one} _____
Yes
_____ No. If yes, attach a copy of the Agreement for Relocation to the Petition.

Failure to obtain an Order prior to the relocation renders the petition to relocate legally insufficient.

SECTION IV. PARENTING PLAN ESTABLISHING PARENTAL RESPONSIBILITY AND TIME-SHARING

1. The minor child(ren) currently reside(s) with _____ Mother _____ Father _____ Other Person:
{explain} ____________________________________________________________________.

2. Parental Responsibility.
It is in the child(ren)’s best interests that parental responsibility be: {Choose only one}
c. ____ shared by both Father and Mother.

d. ____ awarded solely to _____ Father _____ Mother. Shared parental responsibility would be
detrimental to the child(ren) because:_______________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.

3. Parenting Plan and Time-Sharing.
It is in the best interests of the child(ren) that the family be ordered to comply with a Parenting Plan
that _____ includes _____ does not include parental time-sharing with the child(ren). It is in the
best interests of the child (ren) that:
{Choose only one}
a. _____ The attached proposed Parenting Plan should be adopted by the court. The parties:

Florida Supreme Court Approved Family Law Form 12.950(c), Petition for Dissolution of Marriage with Dependent
or Minor Child(ren) and Relocation (03/15)
- 362 -
_____ have _____ have not agreed to the Parenting Plan.

b. _____ The court should establish a Parenting Plan with the following provisions:
_____ No time-sharing for the ____ Father ____ Mother.
_____ Limited time-sharing with the ____ Father _____Mother.
_____ Supervised Time-Sharing for the ____ Father _____Mother.
_____ Supervised or third-party exchange of the child(ren).
____ Time-Sharing Schedule as follows:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.

4. The proposed post-relocation transportation arrangements are as follows:
_____________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________.

5. Explain why the relocation time-sharing schedule is in the best interests of the child(ren):
_________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
.

SECTION V. CHILD SUPPORT
{Indicate all that apply}
7. ____Husband _____Wife requests that the Court award child support as determined by Florida’s
child support guidelines, section 61.30, Florida Statutes. A completed Child Support Guidelines
Worksheet, Florida Family Law Rules of Procedure Form 12.902(e), is, or will be filed. Such support
should be ordered retroactive to:
d. ____ the date of separation {date} _________________
e. ____the date of the filing of this petition.
f. ____ other {date}_________________ {explain} ______________________________________
8. ____ Husband _____Wife requests that the Court award child support to be paid beyond the
age of 18 years because:
a. _____ the following child(ren): {name(s)} _____________________________________________
is (are) dependent because of a mental or physical incapacity which began before the age of 18.
{explain}_______________________________________________________________________
______________________________________________________________________________
b. _____ the following child(ren): {name(s)} ____________________________________________
is (are) dependent in fact; is (are) in high school; between the ages of 18 and 19; and is (are)
performing in good faith with reasonable expectation of graduation before the age of 19.
9. ____Husband _____Wife requests that the Court award a child support amount that is more
than or less than Florida’s child support guidelines. _____Husband _____Wife understands that
Motion to Deviate from Child Support Guidelines, Florida Supreme Court Approved Family Law Form

Florida Supreme Court Approved Family Law Form 12.950(c), Petition for Dissolution of Marriage with Dependent
or Minor Child(ren) and Relocation (03/15)
- 363 -
12.943, must be filed before the court will consider this request.
10. ____Husband _____Wife requests that medical/dental insurance for the minor child(ren) be
provided by:
{Choose only one}
c. ____ Father.
d. ____ Mother.
11. _____Husband _____Wife requests that uninsured medical/dental expenses for the child(ren)
be paid: {Choose only one}
f. ____by Father.
g. ____by Mother.
h. ____by Father and Mother [each pay one-half].
i. ____according to the percentages in the Child Support Guidelines Worksheet, Florida Family
Law Rules of Procedure Form 12.902(e).
j. ____Other {explain}: ____________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
12. _____Husband _____Wife requests that life insurance to secure child support be provided by:
a. ____Husband
b. ____Wife
c. ____Both.

SECTION VI. OTHER
3. {If applicable} _____Wife requests to be known by her former name, which was {full legal
name}___________________________________________________________________________.

4. Other relief {specify}:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

SECTION VII. REQUEST (This section summarizes what you are asking the Court to include in the final
judgment of dissolution of marriage.)
_____Husband _____Wife requests that the Court enter an order dissolving the marriage and:
{Indicate all that apply}
7. _____distribute marital assets and liabilities as requested in Section I of this petition;
8. _____award spousal support (alimony) as requested in Section II of this petition;
9. _____adopt or establish a Parenting Plan containing provisions for parental responsibility and
time-sharing for the dependent or minor child(ren) common to both parties, as requested in Section
IV of this petition;
10. _____permit relocation in accordance with Section III of this petition;
11. _____establish child support for the dependent or minor child(ren) common to both parties, as
requested in Section V of this petition;
12. _____restore Wife’s former name as requested in Section VI of this petition;

Florida Supreme Court Approved Family Law Form 12.950(c), Petition for Dissolution of Marriage with Dependent
or Minor Child(ren) and Relocation (03/15)
- 364 -
13. _____award other relief as requested in Section VI of this petition; and any other terms the
Court deems necessary.

A RESPONSE TO THE PETITION OBJECTING TO THE RELOCATION MUST BE MADE IN WRITING, FILED
WITH THE COURT, AND SERVED ON THE SPOUSE SEEKING TO RELOCATE WITHIN 20 DAYS AFTER
SERVICE OF THIS PETITION TO RELOCATE. IF YOU FAIL TO TIMELY OBJECT TO THE RELOCATION, THE
RELOCATION WILL BE ALLOWED, UNLESS IT IS NOT IN THE BEST INTERESTS OF THE CHILD, WITHOUT
FURTHER NOTICE AND WITHOUT A HEARING.

The Response is in the form of an Answer and it must be sworn to under oath and must include the
specific factual basis supporting the reasons for objecting to the relocation, including a statement of the
amount of participation or involvement you currently have or have had in the life of the child(ren).

Dated: ______________________ _____________________________________________
Signature of _____ HUSBAND _____WIFE

Printed Name: _________________________________
Address: _____________________________________
City, State, Zip: ________________________________
Telephone Number: _____________________________
Fax Number: __________________________________
Designated E-mail Address(es):____________________

STATE OF FLORIDA
COUNTY OF ____________________

Sworn to or affirmed and signed before me on ____________ by _______________________________.

_____________________________________________
NOTARY PUBLIC or DEPUTY CLERK

_____________________________________________
[Print, type, or stamp commissioned name of notary or
deputy clerk.]
____ Personally known
____ Produced identification
____ Type of identification produced ________________________________

Florida Supreme Court Approved Family Law Form 12.950(c), Petition for Dissolution of Marriage with Dependent
or Minor Child(ren) and Relocation (03/15)
- 365 -
IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the _____Husband _____Wife
This form was completed with the assistance of:
{name of individual} _______________________________________________________________ ,
{name of business}__________________________________________________________________ ,
{address} __________________________________________________________________________ ,
{city} ________________,{state} ____, {zip code}__________,{telephone number} ________________.

Florida Supreme Court Approved Family Law Form 12.950(c), Petition for Dissolution of Marriage with Dependent
or Minor Child(ren) and Relocation (03/15)
- 366 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY
LAW FORM 12.950(d)
SUPPLEMENTAL PETITION TO PERMIT RELOCATION WITH MINOR
CHILD(REN) (03/15)

When should this form be used?

This form should be used when you are asking the court to permit the relocation of the principal
residence of the petitioner if:

1. You plan to relocate your residence more than 50 miles from your principal residence at
the time of entry of the last order which established or modified primary residence, custody,
visitation, or time-sharing;

2. The court has not entered an order granting permission to relocate.

3. The relocation will be for a period of 60 consecutive days or more, not including any
absence for purposes of vacation, education, or health care for the child(ren).

4. Your order regarding custody, primary residence, visitation, time-sharing or parenting
plan was entered before October 1, 2009 and the order does not expressly govern the
relocation of the child(ren); was entered on or after October 1, 2006; or your case was
pending on October 1, 2009.

This form should be typed or printed in black ink. You must fill in all sections of the form. After
completing the form, you should sign the form before a notary public or deputy clerk. You
should file this form in the county where the original order was entered. If the order was
entered in another state, or if the child(ren) live(s) in another state, you should speak with an
attorney about where to file this form. You should file the original with the clerk of the circuit
court and keep a copy for your records.

IMPORTANT INFORMATION REGARDING E-FILING

The Florida Rules of Judicial Administration now require that all petitions, pleadings, and
documents be filed electronically except in certain circumstances. Self-represented litigants
may file petitions or other pleadings or documents electronically; however, they are not
required to do so. If you choose to file your pleadings or other documents electronically, you
must do so in accordance with Florida Rule of Judicial Administration 2.525, and you must follow
the procedures of the judicial circuit in which you file. The rules and procedures should be
carefully read and followed.

Instructions for Florida Supreme Court Approved Family Law Form 12.950(d), Supplemental Petition to
Permit Relocation with Child(ren) (03/15)
- 367 -
IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

To serve and receive documents by e-mail, you must designate your e-mail addresses by using
the Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family
Law Form 12.915, and you must provide your e-mail address on each form on which your
signature appears. Please CAREFULLY read the rules and instructions for: Certificate of Service
(General), Florida Supreme Court Approved Family Law Form 12.914; Designation of Current
Mailing and E-mail Address, Florida Supreme Court Approved Family Law Form 12.915; and
Florida Rule of Judicial Administration 2.516.

What should I do next?
For your case to proceed, you must properly notify the other parent and every other person
entitled to, access, time-sharing, or visitation with the child(ren) in your case of the
supplemental petition. “Other Person” means an individual who is not the parent but with
whom the child resides pursuant to court order, or who has the right of access to, time-sharing
with, or visitation with the child(ren). If you know where he or she lives, you should use
personal service. If you absolutely do not know where he or she lives, you may use constructive
service. You may also be able to use constructive service if the other party resides in another
state or country. However, if constructive service is used, the court may only grant limited
relief. For more information on constructive service, see Notice of Action For, Florida Supreme
Court Approved Family Law Form 12.913(a)(2), and Affidavit of Diligent Search and Inquiry,
Florida Family Law Rules of Procedure Form 12.913(b). If the other party is in the military
service of the United States, additional steps for service may be required. See, for example,
Memorandum for Certificate of Military Service, Florida Supreme Court Approved Family Law
Form 12.912(a). The law regarding constructive service and service on an individual in the
military service is very complex. If you have any questions about service, you may wish to
consult an attorney regarding these issues.

If personal service is used, the other party has 20 days to answer after being served with your
supplemental petition. Your case will then generally proceed in one of the following three ways:

DEFAULT... If after 20 days, no answer has been filed, you may file a Motion for Default, Florida
Supreme Court Approved Family Law Form 12.922(a), with the clerk of court. Then, if you have

Instructions for Florida Supreme Court Approved Family Law Form 12.950(d), Supplemental Petition to
Permit Relocation with Child(ren) (03/15)
- 368 -
filed all of the required papers, you may call the clerk, family law intake staff, or judicial
assistant to set a final hearing. You must notify the other party of the hearing by using a Notice
of Hearing (General), Florida Supreme Court Approved Family Law Form 12.923, or other
appropriate notice of hearing form.

UNCONTESTED... If the respondent files either an answer that agrees with everything in your
supplemental petition or an answer and waiver, and you have complied with mandatory
disclosure and filed all of the required papers, you may call the clerk, family law intake staff, or
judicial assistant to set a final hearing. You must notify the other party of the hearing by using a
Notice of Hearing (General), Florida Supreme Court Approved Family Law Form 12.923, or other
appropriate notice of hearing form.

CONTESTED... If the respondent files either an answer or an answer and counterpetition, which
disagrees with or denies anything in your supplemental petition, and you are unable to settle
the disputed issues, you should file a Notice for Trial, Florida Supreme Court Approved Family
Law Form 12.924, after you have complied with mandatory disclosure and filed all of the
required papers. Some circuits may require the completion of mediation before a final hearing
may be set. Then you should contact the clerk, family law intake staff, or judicial assistant for
instructions on how to set your case for trial (final hearing). If the respondent files an answer
and counterpetition, you should answer the counterpetition within 20 days using an Answer to
Counterpetition, Florida Supreme Court Approved Family Law Form 12.903(d).

Where can I look for more information?

Before proceeding, you should read “General Information for Self-Represented Litigants”
found at the beginning of these forms. The words that are in “bold underline” in these
instructions are defined there. For further information, see chapter 61, Florida Statutes.

Special notes...

If you do not have the money to pay the filing fee, you may obtain an Application for
Determination of Civil Indigent Status from the clerk, fill it out, and the clerk will determine
whether you are eligible to have filing fees deferred.

If there is a domestic violence case and you want to keep your address confidential for safety
reasons, do not enter the address, telephone number, and fax information at the bottom of this
form. Instead, file a Request for Confidential Filing of Address, Florida Supreme Court
Approved Family Law Form 12.980(h).

With this form, you must also file the following:

 Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida
Supreme Court Approved Family Law Form 12.902(d).

Instructions for Florida Supreme Court Approved Family Law Form 12.950(d), Supplemental Petition to
Permit Relocation with Child(ren) (03/15)
- 369 -
 Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form
12.902(e). (If you do not know the other party’s income, you may file this worksheet after
his or her financial affidavit has been served on you.)
 Agreement for Relocation, if you have reached an agreement on any or all of the issues
attach the proposed Agreement For Relocation with Minor Child(ren). Florida Supreme
Court Approved Family Law 12.950(a). Both parties must sign this agreement before a
notary public. Any issues on which you are unable to agree will be considered contested
and settled by the judge at the final hearing.
 Notice of Social Security Number, Florida Supreme Court Approved Family Law Form
12.902(j), if not previously filed.
 Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or
(c).
 Certificate of Compliance with Mandatory Disclosure, Florida Family Law Rules of
Procedure Form 12.932. (This must be filed within 45 days of service of the supplemental
petition on the respondent, if not filed at the time of the supplemental petition, unless you
and the other party have agreed not to exchange these documents.)

Updating Information. A parent or other person seeking to relocate has a continuing duty to
provide current and updated information required by the relocation statute when that
information becomes known.

Parenting and Time-Sharing... If you and the other parent and every other person entitled to
access to or time-sharing with the child(ren) are unable to agree on the parenting arrangements
and a time-sharing schedule, a judge will decide for you as part of establishing a Parenting Plan.
The judge will decide the parenting arrangements and a time-sharing schedule based upon the
child(ren)’s best interests. Regardless of whether there is an agreement, the court reserves
jurisdiction to modify issues relating to the minor child(ren).

Failure to obtain an Order prior to relocation renders the supplemental petition to relocate
legally insufficient.

If one has not already been completed, the court may require the completion of a parenting
course before a final hearing is set. You should contact the clerk, family law intake staff, or
judicial assistant about requirements for parenting courses or mediation where you live.

Instructions for Florida Supreme Court Approved Family Law Form 12.950(d), Supplemental Petition to
Permit Relocation with Child(ren) (03/15)
- 370 -
take into account the financial contributions of both parents. You must file a Family Law
Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or (c), and the other
parent will be required to do the same. From your financial affidavits, you should be able to
calculate the amount of child support that should be paid using the Child Support Guidelines
Worksheet, Florida Family Law Rules of Procedure Form 12.902(e). Because the child support
guidelines take several factors into consideration, change over time, and vary from state to
state, your child support obligation may be more or less than that of other people in seemingly
similar situations.

Temporary Relief... If you need temporary relief regarding relocation of the minor child(ren),
complete paragraph eleven contained in the Supplemental Petition To Permit Relocation of
Minor Child(ren).

Final Judgment Form... These family law forms contain a Final Judgment/Supplemental Final
Judgment Permitting Relocation, Florida Supreme Court Approved Family Law Form 12.950(i),
which the judge may use. You should check with the clerk, family law intake staff, or judicial
assistant to see if you need to bring it with you to the hearing. If so, you should type or print the
heading, including the circuit, county, case number, division, and the parties’ names, and leave
the rest blank for the judge to complete at your hearing or trial.

Nonlawyer... Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer
helps you fill out these forms, that person must give you a copy of a Disclosure from
Nonlawyer, Florida Family Law Rules of Procedure Form 12.900(a), before he or she helps you.
A nonlawyer helping you fill out these forms also must put his or her name, address, and
telephone number on the bottom of the last page of every form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.950(d), Supplemental Petition to
Permit Relocation with Child(ren) (03/15)
- 371 -
IN THE CIRCUIT COURT OF THE _____________________ JUDICIAL CIRCUIT,
IN AND FOR ______________________________ COUNTY, FLORIDA

Case No: ________________________
Division: ________________________

_________________________________,
Petitioner,
And

_________________________________,
Respondent.

SUPPLEMENTAL PETITION TO PERMIT RELOCATION
WITH MINOR CHILD(REN)

I, {full legal name} _____________________________________, being sworn, certify that the
following information is true:

1. The parties to this action were granted a final judgment of _____ dissolution of marriage
_____paternity on {date} ____________________. A copy of the final judgment and any
modification(s) is/are attached to this supplemental petition.

2. {If applicable} The following other person is an individual who is not a parent but with
whom the child resides pursuant to court order, or who has the right of access to, time-
sharing with, or visitation with the child(ren) ______________________________________.

3. Paragraph(s) _____________________ of the _____ final judgment or _____ most recent
modification thereof describes the present custody, visitation, and/or time-sharing ordered.

4. The parties ______have ______have not reached an agreement on relocation. If yes, a copy
of the agreement is attached to this supplemental petition.

5. The parties’ dependent or minor child(ren) is (are):
Name Birth Date
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

6. Since the final judgment or last modification thereof, there has been a substantial change in
circumstances, requiring a modification of the present visitation or time-sharing schedule
because I seek to relocate my principal residence at least 50 miles from my principal
residence. Pursuant to Section 61.13001(3), Florida Statutes, the following information is
provided:

Florida Supreme Court Approved Family Law Form 12.950(d), Supplemental Petition to Permit Relocation
with Child(ren) (03/15)
- 372 -
a. The location of the intended new residence, including the state, city, and physical
address, (if known), is:_____________________________________________________
________________________________________________________________________

b. The mailing address of the new physical residence, if not the same as the physical
address, is: ______________________________________________________________
________________________________________________________________________
________________________________________________________________________

c. The home telephone number of the intended new residence, (if known), is: __________

d. The date of the intended move or proposed relocation is: _________________________

7. The specific reasons for the proposed relocation are: ________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________.
Attach additional sheets if necessary.

8. One of the reasons for the proposed relocation is a job offer. {Choose only one} ____ Yes
_____ No. The job offer is in writing. {Choose only one} _____ Yes _____ No. A copy of the
written job offer is attached to this supplemental petition.

9. I ask the Court to modify access and time-sharing as follows:

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________.

10. This modification is in the best interests of the child(ren) because: {explain}
_____________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________.

11. If the requested modification is granted, Petitioner requests that child support be
modified, consistent with the modification of visitation or time-sharing. A Child Support
Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e), is, or will be

Florida Supreme Court Approved Family Law Form 12.950(d), Supplemental Petition to Permit Relocation
with Child(ren) (03/15)
- 373 -
filed. {Choose only one} _____ Yes _____ No.

12. I am requesting a temporary relief hearing to permit relocation prior to the final
hearing. {Choose only one} _____ Yes _____ No. If yes, explain why you cannot wait for a
final hearing date.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________.

Failure to obtain an Order prior to relocation renders the supplemental petition to relocate
legally insufficient.

13. A completed Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form
12.902(b) or (c), _____is, or _____will be, filed.

14. A completed Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA)
Affidavit, Florida Supreme Court Approved Family Law Form 12.902(d), is filed with this
petition.

15. If not previously filed in this case, a completed Notice of Social Security Number, Florida
Supreme Court Approved Family Law Form 12.902(j), is filed with this petition.

16. Other: __________________________________________________________________
________________________________________________________________________.

A RESPONSE TO THE SUPPLEMENTAL PETITION OBJECTING TO RELOCATION MUST BE MADE IN
WRITING, FILED WITH THE COURT, AND SERVED ON THE PARENT OR OTHER PERSON SEEKING
TO RELOCATE WITHIN 20 DAYS AFTER SERVICE OF THIS SUPPLEMENTAL PETITION TO
RELOCATE. IF YOU FAIL TO TIMELY OBJECT TO THE RELOCATION, THE RELOCATION WILL BE
ALLOWED, UNLESS IT IS NOT IN THE BEST INTERESTS OF THE CHILD, WITHOUT FURTHER
NOTICE AND WITHOUT A HEARING.

A response is in the form of an Answer and it must be sworn to under oath and must include the
specific factual basis supporting the reasons for objecting to the relocation, including a
statement of the amount of participation or involvement you currently have or have had in the
life of the child(ren).

I understand that I am swearing or affirming under oath to the truthfulness of the claims
made in this petition and that the punishment for knowingly making a false statement
includes fines and/or imprisonment.

Dated: ______________________ _______________________________________
Signature of PETITIONER
Printed Name: ___________________________

Florida Supreme Court Approved Family Law Form 12.950(d), Supplemental Petition to Permit Relocation
with Child(ren) (03/15)
- 374 -
Address:________________________________
City, State, Zip:___________________________
Telephone Number:_______________________
Fax Number: ____________________________
Designated E-mail Address(es):_____________

STATE OF FLORIDA
COUNTY OF ____________________

Sworn to or affirmed and signed before me on ____________ by _________________________.

_______________________________________
NOTARY PUBLIC or DEPUTY CLERK

_______________________________________
[Print, type, or stamp commissioned name of
notary or deputy clerk.]

____ Personally known
____ Produced identification
____ Type of identification produced ________________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS
BELOW: [fill in all blanks] This form was prepared for the Petitioner.
This form was completed with the assistance of:
{name of individual} _______________________________________________________ ,
{name of business}_______________________________________________________ ,
{address} ____________________________________________________________________ ,
{city} ______________,{state} ____, {zip code}________{telephone number} _______________.

Florida Supreme Court Approved Family Law Form 12.950(d), Supplemental Petition to Permit Relocation
with Child(ren) (03/15)
- 375 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.950(e)
MOTION FOR TEMPORARY ORDER GRANTING RELOCATION
(03/15)

When should this form be used?

This form should be used when you have filed a Petition or Supplemental Petition to permit relocation
of a child or children, or you are seeking relocation in a pending action. You should use this form to ask
the court to permit a temporary relocation of the child(ren)’s principal residence, temporary
modification of visitation or time-sharing, temporary modification of child support, and other relief
before the court has had an opportunity to make a permanent decision on the question of relocation.

This form should be typed or printed in black ink. You must fill in all sections of the form. After
completing this form, you should file the original with the clerk of the circuit court in the county where
the Petition or Supplemental Petition for Modification to Permit Relocation with Minor Child(ren) was
filed and keep a copy for your records.

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?

A copy of this form, along with all of the other forms required with this motion, must be mailed, e-
mailed, or hand-delivered to the other party in your case. When you have filed all of the required forms,
you are ready to set a hearing on your motion. You should check with the clerk, family law intake staff,
or judicial assistant for information on the local procedure for scheduling a hearing. When you know
the date and time of your hearing, you should notify the other party using a Notice of Hearing
(General), Florida Supreme Court Approved Family Law Form 12.923, or other appropriate notice of
hearing form.

Instructions for Florida Supreme Court Approved Family Law Form 12.950 (e), Motion for Temporary Order
Granting Relocation (03/15)
- 376 -
IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Where can I look for more information?

Before proceeding, you should read “General Information for Self-Represented Litigants” found at the
beginning of these forms. Words in “bold underline” in these instructions are defined there. For
further information, see chapter 61, Florida Statutes.

Special notes...

If the temporary relocation of the child(ren) is approved, the court may require you to provide
reasonable security, financial or otherwise, and guarantee that the court-ordered contact with the
child(ren) will not be interrupted or interfered with by you.

If the relocation is not permitted and the child(ren) is/are relocated nevertheless, there could be serious
consequences affecting the person violating the court order, including his or her parental responsibility
and time-sharing or access with the child(ren)

With this form you must also file the following, if not already filed:

Instructions for Florida Supreme Court Approved Family Law Form 12.950 (e), Motion for Temporary Order
Granting Relocation (03/15)
- 377 -
 Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida
Supreme Court Approved Family Law Form 12.902(d).
 Notice of Social Security Number, Florida Supreme Court Approved Family Law Form
12.902(j).
 Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or (c).
(This must be filed within 45 days if not filed at the time of the petition.)
 Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form
12.902(e), if you are asking for a temporary modification of child support. (If you do not
know the other party’s income, you may file this worksheet as soon as a copy of his or her
financial affidavit has been served on you.)

Temporary Order... These family law forms contain a Temporary Order Granting/Denying Relocation,
Florida Supreme Court Approved Family Law Form 12.950(f) which the judge may use. You should check
with the clerk, family law intake staff, or judicial assistant to see if you need to bring it with you to the
hearing. If so, you should type or print the heading, including the circuit, county, case number, division,
and the parties’ names, and leave the rest blank for the judge to complete at your hearing.

Nonlawyer. Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps
you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida
Family Law Rules of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill
out these forms also must put his or her name, address, and telephone number on the bottom of the
last page of every form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.950 (e), Motion for Temporary Order
Granting Relocation (03/15)
- 378 -
IN THE CIRCUIT COURT OF THE _____________________ JUDICIAL CIRCUIT,
IN AND FOR ______________________________ COUNTY, FLORIDA

Case No: ________________________
Division: ________________________

_________________________________,
Petitioner,
And

_________________________________,
Respondent.

MOTION FOR TEMPORARY ORDER GRANTING RELOCATION

The ____ Petitioner ____ Respondent requests that the Court enter a temporary order
permitting relocation of the minor child(ren).

1. I have filed a Petition or a Supplemental Petition to Permit Relocation to the following:

a. The location of the intended new residence, including the state, city, and physical address, if
known, is ________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

b. The new principal residence is more than 50 miles from my principal place of residence at
the time of the entry of the last order establishing or modifying time-sharing, or at the time of
filing the pending action to establish or modify time-sharing. The change of location is at least
50 miles from that residence and is for at least 60 consecutive days.

c. The mailing address of the new physical residence, if not the same as the physical address,
is:
______________________________________________________________________________
______________________________________________________________________________.

d. The home telephone number of the intended new residence, if known, is _______________.

e. The date of the intended move or proposed relocation is:____________________________.

2. The dependent or minor child(ren) is (are):
Name Birth Date
______________________________________________________________________________
______________________________________________________________________________
Florida Supreme Court Approved Family Law Form 12.950(e), Motion for Temporary Order Granting Relocation
(03/15)
- 379 -
______________________________________________________________________________
______________________________________________________________________________

3. A petition or supplemental petition to relocate has been filed with the court and was served on the
_____ Petitioner _____ Respondent _____ Other Person {name} ______________________ entitled
to access or time-sharing with the child(ren) on ___________________________________ .

_____ A response objecting to the Relocation was filed
OR
_____ The time for filing a response has not passed as of the filing of this Motion.

4. The specific reasons for the proposed temporary relocation of the child(ren) are: ________________
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________.
{Attach additional sheets if necessary.}

5. One of the reasons for the proposed temporary relocation is a job offer.
{Choose one only}_____Yes _____ No.
The job offer is in writing. {Choose one only} _____ Yes _____ No.
If yes, a copy of the written job offer is attached to this Motion.

6. I am requesting a temporary relief hearing to permit relocation and cannot wait for the final hearing
because __________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________.

7. The temporary relocation is in the best interests of the child(ren) because: {explain} ____________
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________.

8. I ask the Court to temporarily establish or modify visitation or the time-sharing schedule as follows:
{explain} __________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________.
__________________________________________________________________________________

9. {Choose only one} ____ Yes ____ No. I ask the Court to temporarily modify child support, consistent
with the modification of visitation or the time-sharing schedule. A Child Support Guidelines
Worksheet, Florida Family Law Rules of Procedure Form 12.902(e),_____ is, or_____ will be filed.

Florida Supreme Court Approved Family Law Form 12.950(e), Motion for Temporary Order Granting Relocation
(03/15)
- 380 -
10. Other Relief. {specify}_______________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

11. A completed Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida
Supreme Court Approved Family Law Form 12.902(d), is filed with this motion or has already been
filed with the Court.

12. A completed Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b)
or (c), is filed with this motion or has already been filed with the Court.

13. A completed Notice of Social Security Number, Florida Supreme Court Approved Family Law Form
12.902(j), is filed with this motion or has already been filed with the Court.

14. I request that the Court hold a hearing on this matter and grant the relief specifically requested and
any other relief this Court may deem just and proper.

I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-
delivered to the person(s) listed below on {date} _______________________________.

Other party or his/her attorney:
Name: ________________________________________
Address: ______________________________________
City, State, Zip: _________________________________
Fax Number: __________________________________
Designated E-mail Address(es):___________________
____________________________________________

_____________________________________________
Signature of Party or his/her attorney
Printed Name: _________________________________
Address: ______________________________________
City, State, Zip: _________________________________
Telephone Number: _____________________________
Fax Number: __________________________________
Designated E-mail Address(es):____________________
_____________________________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the {choose only one} ( ) Petitioner ( ) Respondent

Florida Supreme Court Approved Family Law Form 12.950(e), Motion for Temporary Order Granting Relocation
(03/15)
- 381 -
This form was completed with the assistance of:
{name of individual} ________________________________________________________________,
{name of business}__________________________________________________________________,
{address} _________________________________________________________________________,
{city} _______________,{state} _____, {zip code}__________{telephone number} _______________.

Florida Supreme Court Approved Family Law Form 12.950(e), Motion for Temporary Order Granting Relocation
(03/15)
- 382 -
IN THE CIRCUIT COURT OF THE ___________ JUDICIAL CIRCUIT,
IN AND FOR ___________________ COUNTY, FLORIDA

Case No:_____________________
Division:_____________________

_______________________________
Petitioner,
and
_______________________________
Respondent.

TEMPORARY ORDER GRANTING/ DENYING RELOCATION
The cause came before this Court for a hearing on a Motion for Temporary Order Permitting Relocation.
The Court, having reviewed the file and heard the testimony, makes these findings of fact and ORDERS as
follows:

SECTION I: FINDINGS
1. The Court has jurisdiction over the subject matter and the parties.

2. The last order establishing or modifying parental responsibility, visitation, or time-sharing was
entered on {date}_________________________________.

3. The parties’ dependent or minor child(ren) is/are:
Name Birth Date
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

4. The ____ Petitioner ____ Respondent has filed a Motion for Temporary Order Permitting
Relocation to {address of intended new residence}
__________________________________________________
__________________________________________________________________________________.

5. The new location is more than 50 miles from the principal place of residence at the time of the
entry of the last order establishing or modifying the parenting plan or time-sharing schedule, or at
the time of filing of the pending action, and the relocation is for a period of at least 60 consecutive
days.

6. The other parent or person who is entitled to access, visitation, or time-sharing:

Florida Supreme Court Approved Family Law Form 12.950(f), Temporary Order Granting/Denying Relocation (03/15)
- 383 -
_____ has filed an Answer agreeing with the relocation;
_____ has filed an Answer objecting to the relocation;
_____ has failed to file a timely Answer.

SECTION II: GRANTING OF TEMPORARY ORDER PERMITTING RELOCATION
[Please indicate all that apply]
1. _____The Motion for Temporary Order Permitting Relocation is GRANTED as the Court finds:
The petition to relocate was properly filed and is otherwise in compliance with the requirements of
Section 61.13001(3), Florida Statutes;

AND

From an examination of the evidence presented at the preliminary hearing, there is a likelihood that
at a final hearing the court will approve the relocation of the child, based upon the factors set forth in
Section 61.13001(7), Florida Statutes.
Facts in support of finding:_________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

2. _____ Security: The Temporary Order Permitting Relocation ____ IS ____ IS NOT conditioned
upon the ____ Petitioner ____ Respondent providing reasonable security by:
[If security is required, please indicate all that apply]
a. _____ Posting bond in the amount of $______________ with the clerk of this Court;
b. _____Providing:
________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
c. _____Guaranteeing that the court-ordered contact with the child(ren) will not be interrupted or
interfered with by the relocating party by
____________________________________________________________________________
____________________________________________________________________________

3. _____ Time-Sharing. To ensure that the child(ren) has/have frequent, continuing, and meaningful
contact, access, and time-sharing, the nonrelocating parent or person entitled to access shall have:
{Please choose only one}

a. _____ reasonable time-sharing with the parties’ minor child(ren) after reasonable notice
and as agreed to by the parties. The Court reserves jurisdiction to set a specific schedule;

b. _____ the following specified time-sharing with the parties’ minor child(ren):
_______________
_______________________________________________________________________________

Florida Supreme Court Approved Family Law Form 12.950(f), Temporary Order Granting/Denying Relocation (03/15)
- 384 -
_______________________________________________________________________________
_______________________________________________________________________________;

c. _____ time-sharing in accordance with the temporary Parenting Plan attached as
Exhibit _____ and incorporated herein.

4. _____ No Contact. The _____ Petitioner _____ Respondent and/or _____ Other Person entitled to
access or time-sharing shall have no contact with the parties’ minor child(ren) until further court
order, as such contact is detrimental to the welfare of the minor child(ren). {Explain}:
________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

5. _____ Communication via telephone, Internet, web-cam, etc. with the parties’ minor child(ren)
subject to the following limitations {if any}_________________________________________
_______________________________________________________________________________ .

6. _____ Exchange of Minor Child(ren). The exchange of the minor child(ren) shall be on time as
scheduled by the parties. The following conditions, if checked below, shall also apply.
a. _____ The parties shall temporarily exchange the child(ren) at the following location(s):
_______________________________________________________________________________
_______________________________________________________________________________

b. _____ Other conditions for exchange of the child(ren) are as follows:
_______________________________________________________________________________
_______________________________________________________________________________

7. _____ Costs of Transportation

a. _____ The Petitioner shall pay ____% and the Respondent shall pay ____% of the post-
relocation transportation costs.

b. _____ Other
_____________________________________________________________________

8. _____ Child Support. The Court finds that based upon the Temporary Order Granting Relocation, the
____ Petitioner’s____ Respondent’s child support obligation should be temporarily modified in
consideration of the costs of transportation and the respective net incomes of the parents.
[Please choose only one]

a. _____ The amounts in the attached Child Support Guidelines Worksheet, Florida Family Law
Rules of Procedure Form 12.902(e), filed by the _____ Petitioner _____ Respondent are correct.

Florida Supreme Court Approved Family Law Form 12.950(f), Temporary Order Granting/Denying Relocation (03/15)
- 385 -
OR

b. _____ The Court makes the following findings:
The Petitioner’s net monthly income is $_________________.
The Respondent’s net monthly income is $________________.
Monthly child care costs are $____________.
Monthly health/dental insurance costs are $_______________.
Transportation costs are $__________________.

9. _____ Amount. The Obligor’s child support obligation shall be temporarily modified to $___________
per month payable _____ in accordance with Obligor’s payroll cycle, and in any event, at least once a
month _____ {explain} _____________________________________________________, commencing
{date} _______________________ and continuing until further court order.

SECTION III: DENIAL OF TEMPORARY ORDER PERMITTING RELOCATION
[Please indicate all that apply]
1. _____The Motion for Temporary Order Permitting Relocation is DENIED because:

a. _____ The petition to relocate does not comply with subsection (3) of Section 61.13001,
Florida Statutes;

b. _____ The child(ren) has/have already been relocated without a written agreement of
the parties or without court approval;

c. _____ From an examination of the evidence presented at the preliminary hearing, there
is a likelihood that upon final hearing, relocation of the child(ren) would not be
approved.
Facts in support of finding: _________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________.

2. _____ Temporary Injunction Prohibiting Relocation of Child(ren)
The Court hereby temporarily prohibits and enjoins the _____ Petitioner _____ Respondent
from relocating and removing the child(ren) from the jurisdiction of this Court during the
pendency of this proceeding, or until further order of this Court.
The Court may enforce compliance with this restraining order through civil and/or indirect
criminal contempt proceedings, which may include arrest, incarceration, and/or the
imposition of a fine.

3. _____ Immediate Return of Child(ren)
The _____ Petitioner_____ Respondent has failed to comply with the relocation procedures
set forth in Section 61.13001, Florida Statutes, and has relocated the child(ren) in violation of
that section. The _____ Petitioner _____ Respondent shall immediately return the child(ren)

Florida Supreme Court Approved Family Law Form 12.950(f), Temporary Order Granting/Denying Relocation (03/15)
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to the jurisdiction of this Court.

Failure to immediately return the child(ren) shall subject the non-complying party to
contempt and other proceedings to compel return of the child(ren) and may be taken into
account in any initial or post judgment action seeking a determination or modification of
the parenting plan or time-sharing schedule.

SECTION IV: OTHER

1. Other Provisions:
__________________________________________________________________________________
__________________________________________________________________________________

2. The Court reserves jurisdiction to modify and enforce this Temporary Order regarding relocation.

3. Unless specifically modified by this Temporary Order, the provisions of all final judgments or
orders remain in effect.

4. No weight shall be given to the decision to grant or deny the temporary relocation as a factor in
reaching a final decision.

DONE AND ORDERED at _______________________, Florida, on _____________________.

_____________________________________
CIRCUIT JUDGE

I certify that a copy of this Temporary Order Granting/Denying Relocation was ( ) mailed ( ) faxed
and mailed ( ) e-mailed ( ) hand-delivered to the parties and any entities listed below on
{date} ____________________________.

______________________________________
By: {Clerk of court, designee, or Judicial Assistant}

Florida Supreme Court Approved Family Law Form 12.950(f), Temporary Order Granting/Denying Relocation (03/15)
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Petitioner (or his/her attorney)
Respondent (or his/her attorney)
Central Governmental Depository
Other:_______________________

Florida Supreme Court Approved Family Law Form 12.950(f), Temporary Order Granting/Denying Relocation (03/15)
- 388 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.950(g)
MOTION FOR CIVIL CONTEMPT AND/OR RETURN OF CHILD(REN)
(03/15)

When should this form be used?

You may use this form to ask the court to enforce a prior court order, final judgment or to request the
return of a child(ren) who has been relocated in violation of Section 61.13001, Florida Statutes .

What should I do next?

To initiate a civil contempt/enforcement proceeding against a party who has relocated with a child
contrary to the requirements of a prior court order, or is otherwise not complying with a prior court
order concerning relocation, or in the event there has been a relocation in violation of Section 61.13001,
Florida Statutes, you must file a motion with the court explaining what the party has failed to do. This
form should be typed or printed in black ink. After completing this form, you should sign it before a
notary public or deputy clerk. You should then file the original with the clerk of the circuit court in the
county where your case was filed and keep a copy for your records.

IMPORTANT INFORMATION REGARDING E-FILING

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

SELF-REPRESENTED LITIGANTS MAY SERVE DOCUMENTS BY E-MAIL; HOWEVER, THEY ARE NOT
REQUIRED TO DO SO. If a self-represented litigant elects to serve and receive documents by e-mail, the

Instructions for Florida Supreme Court Approved Family Law Form 12.950(g), Motion for Civil Contempt And/Or
Return of Child(ren) (03/15)
- 389-
procedures must always be followed once the initial election is made.

A copy of this form must be personally served by a sheriff or private process server or mailed*, e-
mailed* or hand delivered to any other party(ies) in your case. *Please note that if notice is mailed or e-
mailed, the court in certain circumstances may not consider mailing or e-mailing to be adequate notice.
If you want to be sure, you should have the motion personally served. This is a technical area of the law;
if you have any questions about it, you should consult a lawyer. For more information on personal
service, see the instructions for Summons: Personal Service on an Individual, Florida Family Law Rules
of Procedure Form 12.910(a).

The court will then set a hearing. You should check with the clerk of court, judicial assistant, or family
law intake staff for information on the local procedure for scheduling a hearing. Once you know the
time and date of the hearing, you will need to complete Notice of Hearing on Motion for
Contempt/Enforcement, Florida Supreme Court Approved Family Law Form 12.961, Florida Supreme
Court Approved Family Law Form 12.921, or Order of Referral to General Magistrate, Florida Family
Law Rules of Procedure Form 12.920(b), which will specify a time and place for a hearing on the issue. A
copy of the form you used to schedule the hearing must be mailed, e-mailed, or hand-delivered to the
other party. Again, if notice is mailed or e-mailed, the court in certain circumstances may not consider
that to be adequate notice. If you want to be sure, you should have the notice personally served. This is
a technical area of the law; if you have any questions about it, you should consult a lawyer. For more
information on personal service, see the instructions for Summons: Personal Service on an Individual,
Florida Family Law Rules of Procedure Form 12.910(a).

At the hearing, as in other civil proceedings, you, as the party seeking contempt or return of children,
will have the burden of proof. The other party will have an opportunity to put on defenses, if any apply.
If the judge finds the other party to be in willful contempt or in violation of Section 61.13001, Florida
Statutes, the judge may order appropriate sanctions to compel compliance or return of the child(ren) by
the other party, including jail, payment of attorneys’ fees, suit money, court costs, coercive or
compensatory fines, and may order any other relief permitted by law.

Where can I look for more information?
Before proceeding, you should read “General Information for Self-Represented Litigants” found at the
beginning of these forms. See also section 61.14, Florida Statutes and rule 12.615, Florida Family Law
Rules of Procedure.

Instructions for Florida Supreme Court Approved Family Law Form 12.950(g), Motion for Civil Contempt And/Or
Return of Child(ren) (03/15)
- 390-
Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.950(g), Motion for Civil Contempt And/Or
Return of Child(ren) (03/15)
- 391-
IN THE CIRCUIT COURT OF THE _____________________ JUDICIAL CIRCUIT,
IN AND FOR ______________________________ COUNTY, FLORIDA

Case No: ________________________
Division: ________________________

_________________________________,
Petitioner,
And

_________________________________,
Respondent.

MOTION FOR CIVIL CONTEMPT AND/OR RETURN OF CHILD(REN)

_____ Petitioner _____ Respondent requests that the Court enter an order of civil contempt and/or an
order for return of child(ren) against _____ Petitioner _____ Respondent because he/she has relocated
with the parties’ minor child(ren) or has taken other action with respect to relocation.
I. NONCOMPLIANCE OR VIOLATION
A. The other party in this case has willfully failed to comply with the: {Choose only one}
1.____ Court order or judgment entered on {date} ________________________, by {court, city,
and state}____________________________________________________________________.
____ Please indicate here if the judgment or order is not from this Court and attach a copy of
the judgment or order to this motion.

2.____ Written Agreement of the parties.

3.____ Relocation procedures of Section 61.13001, Florida Statutes.
B. This order, judgment, agreement, or statute, required the other party in this case to do or
not do the following: {Explain what the other party was ordered to do or not do}
_______________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.
____ Please indicate here if additional pages are attached.

C. The other party in this case has willfully failed to comply with this order or judgment of the
court , a written agreement, or the requirements of Section 61.13001,Florida Statutes:
{Explain what the other party has or has not
done}.___________________________________________
______________________________________________________________________________
______________________________________________________________________________

Florida Supreme Court Approved Family Law Form 12.950(g), Motion for Civil Contempt And/Or Return of
Child(ren) (03/15)
- 392 -
______________________________________________________________________________.
____ Please indicate here if additional pages are attached.
II. REQUEST FOR RELIEF OR SANCTION
A. _____ There IS a prior court order or judgment and I respectfully request that the court
issue an order holding the above-named person in civil contempt, if appropriate, and/or
providing the following relief: {Indicate all that apply}
1. _____ordering the immediate return of the minor child(ren);
2. _____ granting a temporary order restraining the relocation of minor child(ren);
3. _____ enforcing or compelling compliance with the prior order or judgment;
4. _____ requiring the other party to pay costs and fees in connection with this motion;
5. _____ if the other party is found to be in civil contempt, ordering a compensatory fine;
6. _____ if the other party is found to be in civil contempt, ordering a coercive fine;
7. _____ if the other party is found to be in civil contempt, ordering incarceration of the
other party after setting an appropriate purge;
8. _____ issuing a writ of bodily attachment as appropriate;
9. ____ awarding make-up time-sharing with minor child(ren) as follows {explain}
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
10. _____ awarding attorney’s fees; and/or
11. _____ awarding other relief, including sanctions , {explain}:__________________________
___________________________________________________________________________
___________________________________________________________________________

B. ___ There is NO prior court order; however, the above-named person has violated the
requirements of Section 61.13001, Florida Statutes, and I respectfully request that the court
issue an order providing the following relief:
1. _____ ordering the immediate return of the minor child(ren);
2. _____ granting a temporary order restraining the relocation of the minor child(ren);
3. _____ enforcing or compelling compliance with Section 61.13001, Florida Statutes;
4. _____ requiring the other party to pay costs and fees in connection with this motion;
5. _____ awarding make-up time-sharing with minor child(ren) as follows {explain}: _____
___________________________________________________________________________
___________________________________________________________________________
6. _____ awarding attorneys’ fees; and/or
7. _____ awarding other relief, including sanctions, {explain}: __________________________
______________________________________________________________________________
______________________________________________________________________________

Florida Supreme Court Approved Family Law Form 12.950(g), Motion for Civil Contempt And/Or Return of
Child(ren) (03/15)
- 393 -
I certify that a copy of this document was ( ) mailed ( ) faxed and mailed
( ) e-mailed ( ) hand-delivered to the person(s) listed below on {date}_________________.

Other party or his/her attorney:
Name:________________________________________
Address:______________________________________
City, State, Zip:_________________________________
Fax Number: __________________________________
Designated E-mail Address(es):____________________
____________________________________________

Dated: ______________________ _____________________________________________
Signature of Party

Printed Name: ________________________________
Address: ____________________________________
City, State, Zip: ________________________________
Telephone Number: _____________________________
Fax Number: __________________________________
Designated E-mail Address(es):____________________
_____________________________________________

STATE OF FLORIDA
COUNTY OF ____________________

Sworn to or affirmed and signed before me on ____________ by _______________________________.

_____________________________________________
NOTARY PUBLIC or DEPUTY CLERK

_____________________________________________
Florida Supreme Court Approved Family Law Form 12.950(g), Motion for Civil Contempt And/Or Return of
Child(ren) (03/15)
- 394 -
[Print, type, or stamp commissioned name of notary or
deputy clerk.]

____ Personally known
____ Produced identification
____ Type of identification produced ________________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent.
This form was completed with the assistance of:
{name of individual} ___________________________________________________________________ ,
{name of business}____________________________________________________________________ ,
{address} ____________________________________________________________________________ ,
{city} ________________,{state} ____, {zip code}__________,{telephone number} _________________.

Florida Supreme Court Approved Family Law Form 12.950(g), Motion for Civil Contempt And/Or Return of
Child(ren) (03/15)
- 395 -
IN THE CIRCUIT COURT OF THE _____________________ JUDICIAL CIRCUIT,
IN AND FOR ______________________________ COUNTY, FLORIDA

Case No: ________________________
Division: ________________________

_________________________________,
Petitioner,
And

_________________________________,
Respondent.

ORDER ON MOTION FOR CIVIL CONTEMPT FOR
RELOCATION AND/OR RETURN OF CHILD(REN)
A Motion was filed by _____ Petitioner _____ Respondent for Civil Contempt for Improper Relocation
and/or Return of the Minor Child(ren), and the Court finding as follows:

1. _____ Petitioner _____ Respondent has relocated with the parties’ minor child(ren) more than
50 miles from the child(ren)’s principal place of residence at the time of the entry of the last order
establishing or modifying the parenting plan or time-sharing schedule and the relocation places the
child(ren) more than 50 miles away from either parent or other person entitled to access, time-
sharing or visitation;

a. _____ Contrary to a court order or judgment entered on {date} _______________, by this Court;

b. _____ Contrary to a court order or judgment entered on {date}__________________, by {court,
city, and state}__________________________________________________________________.
The order of the Court required the other party in this case to do or not do the following:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________.

c. _____ Contrary to the relocation procedures set forth in Section 61.13001, Florida Statutes.

2. _____ Petitioner _____Respondent has willfully failed to comply either with the order of the
Court or with the requirements of Section 61.13001, Florida Statutes as follows:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________.

Based upon the above findings it is ORDERED AND ADJUDGED as follows:

Florida Supreme Court Approved Family Law Form 12.950 (h), Order on Motion for Civil Contempt for Relocation
And/Or Return of Child(ren) (03/15)
- 396 -
3. _____ The Motion for Civil Contempt for Relocation/Return of Child is hereby GRANTED.

a. ____ Petitioner _____ Respondent is hereby ordered to immediately return the minor child(ren)
to the jurisdiction of this Court.

b. ____ Petitioner _____ Respondent is hereby temporarily restrained from relocating with the
minor child(ren), pending further order of this Court.

c. ____ This Court shall issue a Writ of Bodily Attachment against the _____Petitioner
_____Respondent at the hearing on the Motion for Contempt.

d. ____ Petitioner _____ Respondent may purge himself/herself of the Contempt by immediately
returning the minor child(ren) to the jurisdiction of this Court.

e. ____ Petitioner _____Respondent shall be awarded makeup time-sharing with the minor
child(ren) as follows:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________.

f. ____ The following additional relief, including sanctions, is granted:
___________________________________________________________________________
___________________________________________________________________________ .

4. ____ The Motion For Civil Contempt For Relocation And/Or Return Of Child(ren) is hereby
DENIED.

5. ____ Attorney’s Fees, Costs and Suit Money
a. _____ Petitioner’s _____ Respondent’s request(s) for attorney’s fees, costs, and suit money
is/are denied because___________________________________________________________
___________________________________________________________________________ .
OR
b. _ The Court finds there is a need for and an ability to pay attorney’s fees, costs, and
suit money. _____Petitioner _____ Respondent is hereby ordered to pay to the other party
$___________ in attorney’s fees, and $__________ in costs. The Court further finds that the
attorney’s fees awarded are based on the reasonable rate of $_________ per hour and
________________ reasonable hours. Other provisions relating to attorney fees, costs, and suit
money are as follows: ____________________________________________________________
______________________________________________________________________________

DONE AND ORDERED at ___________________________, Florida, on ___________________________.

Florida Supreme Court Approved Family Law Form 12.950 (h), Order on Motion for Civil Contempt for Relocation
And/Or Return of Child(ren) (03/15)
- 397 -
___________________________________
CIRCUIT JUDGE

I certify that a copy of the Order on Motion for Civil Contempt for Relocation and/or Return of Child(ren)
was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the parties and any
entities listed below on {date} ____________________________.

______________________________________
{Clerk of court, designee, or Judicial Assistant}

Petitioner (or his or her attorney)
Respondent (or his or her attorney)
Other Person (or his or her attorney)
_____________________________

Florida Supreme Court Approved Family Law Form 12.950 (h), Order on Motion for Civil Contempt for Relocation
And/Or Return of Child(ren) (03/15)
- 398 -
IN THE CIRCUIT COURT OF THE _____________________ JUDICIAL CIRCUIT,
IN AND FOR ______________________________ COUNTY, FLORIDA

Case No: ________________________
Division: ________________________

_________________________________,
Petitioner,
And

_________________________________,
Respondent.

FINAL JUDGMENT/SUPPLEMENTAL FINAL JUDGMENT
GRANTING RELOCATION
This cause came before this Court on a Petition/Supplemental Petition to relocate filed by (name)
____________________________________ the _______________________ of the child(ren). The
Court makes these findings of fact and ORDERS as follows:

SECTION I. FINDINGS
1. The Court has jurisdiction over the subject matter and the parties.

2. The last judgment or order establishing or modifying parental responsibility, custody, visitation,
or time-sharing (if any) was entered on (date)________________________.

3. ____ {If Applicable} A prior order or judgment in this cause expressly governs the issue of
relocation of the child(ren).

4. The parties’ dependent or minor child(ren) is (are):
Name(s) Birth Date(s)
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

5. The _____ Petitioner _____ Respondent _____Other Person entitled to access or time-sharing
{name} __________________________________ has filed a petition to relocate to {location/or
address}__________________________________________________________________________,
a location more than 50 miles from his/her principal place of residence at the time of entry of the
last order establishing or modifying time-sharing, or at the time of filing of the pending action to
establish or modify time-sharing. The relocation is for a period of at least 60 consecutive days.

Florida Supreme Court Approved Family Law Form 12.950(i), Final Judgment/Supplemental Final Judgment
Granting Relocation (03/15)
- 399 -
6. This judgment/supplemental judgment was entered: {Choose only one}
_____After a Hearing;

_____Without an evidentiary hearing due to the _____ written agreement of the parties or the
_____ other party’s failure to respond.

SECTION II. GRANTING REQUEST TO RELOCATE
The Court finds that the relocation IS GRANTED based upon:

{Choose only one}
1. _____No response. The other parent or person entitled to access to or time-sharing with the
child(ren) failed to timely file a response objecting to the petition to relocate. The Court finds that
the relocation is in the best interests of the child(ren) based upon the undisputed pleadings. The
access or time-sharing schedule and post-relocation transportation arrangements contained within
the petition are adopted by the Court.

2. _____Agreement. The parents or other person entitled to time-sharing with the child(ren)
agree to the relocation and have signed a written agreement which consents to the relocation;
defines the access or time-sharing schedule for the parents or any other persons entitled to access
and time-sharing, and describes, if necessary, any post-relocation transportation arrangements
relating to access or time-sharing. The Court finds that the relocation is in the best interests of the
child(ren) based upon the pleadings and the Agreement.

A copy of this Agreement is attached as Exhibit _______.

3. _____Evidentiary Hearing. The Court finds that the relocation is in the best interests of the
child(ren) based upon the evidence presented at the evidentiary hearing. The Court has evaluated
each of the factors enumerated in Section 61.13001(7), Florida Statutes, and FINDS:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________.

SECTION III.PARENTAL RESPONSIBILITY AND TIME-SHARING
{Choose only one}

1. ____ Time-Sharing. The _____ Petitioner _____ Respondent _____ Other Person entitled to
access or time-sharing shall have frequent, continuing, and meaningful contact, access, and time-
sharing in accordance with:
{Choose only one}
a. _____the Agreement for Relocation attached as Exhibit ______and incorporated herein.
b. _____the Parenting Plan attached as Exhibit ______and incorporated herein.
c. _____the following specified time-sharing schedule:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Florida Supreme Court Approved Family Law Form 12.950(i), Final Judgment/Supplemental Final Judgment
Granting Relocation (03/15)
- 400 -
______________________________________________________________________________
______________________________________________________________________________

2. _____ No Contact. The _____ Petitioner _____ Respondent _____ Other Person entitled to
access, visitation, or time-sharing shall have no contact with party’s minor child(ren) until further
order of the Court, as such contact is detrimental to the welfare of the minor child(ren).
{Explain} _______________________________________________________________________
_______________________________________________________________________________
________________________________________________________________________________ .

SECTION IV: MODIFICATION OF CHILD SUPPORT
{Indicate all that apply}
1. _____ The Court finds that based upon the relocation, the _____ Petitioner’s _____
Respondent’s child support obligation should be modified in consideration of the costs of
transportation and the respective net incomes of the parents.
{Choose only one}
a. _____ The amounts in the Child Support Guidelines Worksheet, Florida Family Law Rules of
Procedure Form 12.902(e), filed by the _____ Petitioner _____ Respondent are correct and are
adopted by the Court.

OR
b. _____ The Court makes the following findings:
The Petitioner’s net monthly income is $_____________.
The Respondent’s net monthly income is $______________.
Monthly child care costs are $_______________.
Monthly health/dental insurance costs are $_________________.
Transportation costs are $___________________.

2. _____ Amount. The Obligor’s child support obligation shall be modified to $___________ per
month for the ______ children {total amount of parties’ minor or dependent children} commencing:
{month, day, year} and terminating _____________{month, day, year}. Child support shall be paid in
the amount of $__________ per __________________ {week, month, other} consistent with
Obligor’s current payroll cycle.

Upon the termination of the obligation of child support for one of the parties’ children, child support
in the amount of $__________for the remaining ________children {total number of remaining
children} shall be paid commencing _______________________________ {month, day, year} and
terminating_____________________________ {month, day, year}. This child support shall be paid
in the amount of $________per __________ {week, month, other} consistent with the Obligor’s
current payroll cycle.

Florida Supreme Court Approved Family Law Form 12.950(i), Final Judgment/Supplemental Final Judgment
Granting Relocation (03/15)
- 401 -
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
The Obligor shall pay child support until all of the minor or dependent children: reach the age of 18;
become emancipated, marry, join the armed services, die, or become self-supporting; or until
further order of the court or agreement of the parties. The child support obligation shall continue
beyond the age of 18 and until high school graduation for any child who is dependent in fact,
between the ages of 18 and 19, and is still in high school, performing in good faith with a reasonable
expectation of graduation before the age of 19.

If the child support ordered deviates from the guidelines by more than 5%, the factual findings
which support that deviation are: ______________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

SECTION V. METHOD OF PAYMENT
Obligor shall pay modified child support as follows:

1. Place of Payment.

a. ____Obligor shall pay court-ordered support directly to either the State Disbursement
Unit or the central depository, as required by statute, along with any fee required by
statute.

b. ____Both parties have requested and the court finds that it is in the best interests of the
child(ren) that support payments need not be directed through either the State
Disbursement Unit or the central depository at this time; however, either party may
subsequently apply, pursuant to section 61.13(1)(d)3, Florida Statutes, to require
payment through either the State Disbursement Unit or the central depository.

2. Income Deduction.

a. ___Immediate. Obligor shall pay through income deduction, pursuant to a separate Income
Deduction Order which shall be effective immediately. Obligor is individually responsible for
paying this support obligation until all of said support is deducted from Obligor’s income. Until
support payments are deducted from Obligor’s paycheck, Obligor is responsible for making
timely payments directly to the State Disbursement Unit or the Obligee, as previously set forth
in this order.
b. ___Deferred. Income deduction is ordered this day, but it shall not be effective until a
delinquency of $__________, or, if not specified, an amount equal to one month’s obligation
occurs. Income deduction is not being implemented immediately based on the following
findings: Income deduction is not in the best interests of the child(ren) because: {explain}
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________,
AND

Florida Supreme Court Approved Family Law Form 12.950(i), Final Judgment/Supplemental Final Judgment
Granting Relocation (03/15)
- 402 -
There is proof of timely payment of a previously ordered obligation without an Income
Deduction Order in cases of modification,
AND
( ) There is an agreement by the Obligor to advise the Title IV-D agency, the clerk of court, and
the Obligee of any change in Payor and/or health insurance
OR
( ) there is a signed written agreement providing an alternative arrangement between the
Obligor and the Obligee and, at the option of the IV-D agency, by the IV-D agency in IV-D cases
in which there is an assignment of support rights to the state, reviewed and entered in the
record by the court.

SECTION VI. OTHER
1. _____Other Provisions
_________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________.

2. _____The Court reserves jurisdiction to address all issues of time-sharing and parental
responsibility, as well as to enforce or modify the provisions of this Judgment.

3. _____ Unless specifically modified herein, the provisions of all prior judgments or orders remain in
effect.

DONE AND ORDERED at _________________________, Florida, on_____________________.

__________________________________
CIRCUIT JUDGE

I certify that a copy of this Final Judgment/Supplemental Final Judgment Granting Relocation
was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the parties and any
other persons or entities listed below on {date} ____________________________.

______________________________________
{Clerk of court, designee, or Judicial Assistant}

Petitioner (or his/her attorney)
Respondent (or his/her attorney)
Other Person (or his/her attorney)

Florida Supreme Court Approved Family Law Form 12.950(i), Final Judgment/Supplemental Final Judgment
Granting Relocation (03/15)
- 403 -
State Disbursement Unit
Other:_________________________

Florida Supreme Court Approved Family Law Form 12.950(i), Final Judgment/Supplemental Final Judgment
Granting Relocation (03/15)
- 404 -
IN THE CIRCUIT COURT OF THE ___________________ JUDICIAL CIRCUIT
IN AND FOR ___________________________ COUNTY, FLORIDA

Case No:__________________________
Division: __________________________

________________________________________,
Petitioner,
And

________________________________________,
Respondent.

FINAL JUDGMENT/SUPPLEMENTAL FINAL JUDGMENT
DENYING RELOCATION
This cause came before this Court on a Petition/Supplemental Petition to relocate filed by {name}
____________________________________ the _______________________ of the child(ren). The Court
makes these findings of fact and ORDERS as follows:

SECTION I. FINDINGS

1. The Court has jurisdiction over the subject matter and the parties.

2. The last judgment or order establishing or modifying parental responsibility, custody, visitation,
or time-sharing (if any) was entered on {date}_____________________________________.

3. _____ {If Applicable} A prior order or judgment in this cause expressly governs the issue of
relocation of the child(ren).

4. The parties’ dependent or minor child(ren) is (are):
Name Birth Date
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

5. The _____Petitioner _____Respondent _____Other Person entitled to access or time-sharing:
{name}______________________________________ has filed a petition to relocate to: {location
and/oraddress}_____________________________________________________________,a location
more than 50 miles from his/her principal place of residence at the time of entry of the last order
establishing or modifying time-sharing, or at the time of filing of the pending action to establish or
modify time-sharing. The relocation is for a period of more than 60 consecutive days.
Florida Supreme Court Approved Family Law Form 12.950(j), Final Judgment/Supplemental Final Judgment
Denying Relocation (03/15)
- 405 -
The Court has evaluated each of the factors enumerated in Section 61.13001(7), Florida Statutes,
and on the evidence presented, it is adjudged:

SECTION II. DENIAL OF REQUEST TO RELOCATE
The request to relocate is DENIED because:
1. _____ The Petition is legally insufficient as it fails to include a proposed revised post-relocation
schedule for access and time-sharing that includes the necessary arrangements to effectuate time-
sharing with the child(ren).

OR
2. _____ The requested relocation is not in the best interests of the child(ren).
Facts in support of finding:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________.

3. _____Order Requiring Return of Child(ren) if Parent and Child(ren) have Temporarily
Relocated.
The _____ Petitioner _____ Respondent _____ Other Person entitled to access to or time-sharing
with the child(ren) shall immediately return the child(ren) to the jurisdiction of this Court. Failure to
immediately return the child(ren) shall subject the non-complying party to contempt or other
proceedings deemed necessary to compel return of the child(ren).

SECTION III.OTHER
1. ____Other Provisions:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________.

2. _____This Court reserves jurisdiction to address all issues of time-sharing and parental
responsibility, as well as to enforce or modify the provisions of this Judgment.

3. _____Unless specifically modified herein, the provisions of all prior judgments or orders remain
in effect.

DONE AND ORDERED at ________________________, Florida on ______________________ .

__________________________________
CIRCUIT JUDGE

Florida Supreme Court Approved Family Law Form 12.950(j), Final Judgment/Supplemental Final Judgment
Denying Relocation (03/15)
- 406 -
I certify that a copy of this Final Judgment/Supplemental Final Judgment Denying Relocation
was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the parties and any
other persons or entities listed below on {date} ____________________________.

______________________________________
{Clerk of court, designee, or Judicial Assistant}

Petitioner (or his/her attorney)
Respondent (or his/her attorney)
Other Person (or his/her attorney)
State Disbursement Unit

Florida Supreme Court Approved Family Law Form 12.950(j), Final Judgment/Supplemental Final Judgment
Denying Relocation (03/15)
- 407 -
INSTRUCTIONS FOR FLORIDA FAMILY LAW RULES OF PROCEDURE
FORM 12.951(a)
PETITION TO DISESTABLISH PATERNITY AND/OR TERMINATE
CHILD SUPPORT OBLIGATION (03/15)

When should this form be used?
This form should be used by a man who wishes to disestablish paternity or terminate a child
support obligation because he is not the biological father of the child(ren). The petition must be
filed
• in the circuit court having jurisdiction over the child support obligation; or

• if the child support was determined administratively and has not been ratified by a
court, in the circuit court in which the mother or legal guardian or custodian of the
child(ren) resides; or

• if the mother or legal guardian or custodian no longer resides in the state, in the circuit
court in the county in which the petitioner resides.

This form should be typed or printed in black ink. After completing the form, you should sign the
form before a notary public or deputy clerk.

A copy of any judgment or order regarding paternity or child support and a copy of any scientific
test results showing that you cannot be the father of the child(ren) must be attached to the
petition and filed with the court.

IMPORTANT INFORMATION REGARDING E-FILING

The Florida Rules of Judicial Administration now require that all petitions, pleadings, and
documents be filed electronically except in certain circumstances. Self-represented litigants
may file petitions or other pleadings or documents electronically; however, they are not
required to do so. If you choose to file your pleadings or other documents electronically, you
must do so in accordance with Florida Rule of Judicial Administration 2.525, and you must follow
the procedures of the judicial circuit in which you file. The rules and procedures should be
carefully read and followed.

What should I do next?
The petition must be served on the mother or legal guardian or custodian of the child(ren). If the
child support obligation was determined administratively and has not been ratified by a court,
the petition must also be served on the Department of Revenue.

Instructions for Florida Supreme Court Approved Family Law Form 12.951(a), Petition to Disestablish
Paternity and/or Terminate Child Support Obligation (03/15)
- 408 -
IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

To serve and receive documents by e-mail, you must designate your e-mail addresses by using
the Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family
Law Form 12.915, and you must provide your e-mail address on each form on which your
signature appears. Please CAREFULLY read the rules and instructions for: Certificate of Service
(General), Florida Supreme Court Approved Family Law Form 12.914; Designation of Current
Mailing and E-mail Address, Florida Supreme Court Approved Family Law Form 12.915; and
Florida Rule of Judicial Administration 2.516.

Where can I look for more information?
Before proceeding, you should read “General Information for Self-Represented Litigants”
found at the beginning of these forms. For further information, see Section 742.18, Florida
Statutes.

Special notes . . .
Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill
out these forms, that person must give you a copy of Disclosure from Nonlawyer, Florida Family
Law Rules of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill
out these forms also must put his or her name, address, and telephone number on the bottom
of the last page of every form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.951(a), Petition to Disestablish
Paternity and/or Terminate Child Support Obligation (03/15)
- 409 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.: ________________
Division: ________________
,
Petitioner,

and

,
Respondent.

PETITION TO DISESTABLISH PATERNITY AND/OR TERMINATE
CHILD SUPPORT OBLIGATION
I, {full legal name} , certify that the following
information is true.

1. Paternity. My paternity of the child(ren), {name(s) and birth date(s)}

was established by
{Choose only one}
a. operation of law because I was married to the child(ren)’s mother.
b. adjudication of paternity, entered by {court}
on {date} .
c. acknowledgment of paternity executed on {date} .
d. other: {specify}

A copy of any judgment is attached.

2. Child support. My child support obligation for the child(ren), {name(s) and birth
date(s)},
was established by
{Choose only one}
a. a final judgment of dissolution of marriage, entered by {court} ______
_____________________on {date} .
b. an administrative proceeding to establish child support in {location}
______________on {date} .
c. __ a paternity proceeding in {court} on
{date} .
d. __other {specify} _______

A copy of any judgment is attached.

Florida Supreme Court Approved Family Law Form 12.951(a), Petition to Disestablish Paternity and/or
Terminate Child Support Obligation (03/15)
- 410 -
3. Newly discovered evidence. Newly discovered evidence concerning the paternity of
this/these child(ren) has come to my knowledge since the initial paternity determination or
establishment of the child support obligation. {Explain}
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________.

4. Scientific tests.

a. _The results of scientific tests that are generally acceptable within the scientific
community to show a probability of paternity, administered within 90 days prior to the
filing of this petition, indicate that I cannot be the father of the child(ren) for whom
support is required. A copy of the test results is attached.

b. __ I did not have access to the child(ren) to have scientific testing performed before
the filing of this petition and I request that the court order the child(ren) to be tested.

5. Fulfillment of child support obligation.
{Choose only one}
a. __ I am current on all child support payments for the child(ren) for whom relief is
sought.

b. __I have substantially complied with my child support obligation for the child(ren)
and any delinquency in my child support obligation for the child(ren) arose from my
inability for just cause to pay the delinquent child support when the delinquent child
support became due.

I ask the court to enter an order to:

{Indicate all that apply}

a. __ disestablish my paternity to {name(s) of child(ren)} __________________________
____________________________________________________________________

b. __terminate my obligation to pay child support for {name(s) of child(ren)} ___________
________________________________________________________________________

c. __other: ______________________________________________________________
__________________________________________________________________
___________________________________________________________________ .

Florida Supreme Court Approved Family Law Form 12.951(a), Petition to Disestablish Paternity and/or
Terminate Child Support Obligation (03/15)
- 411 -
I certify that a copy of this document was ( ) mailed ( ) faxed and mailed
( ) e-mailed ( ) hand delivered to the person(s) listed below on {date} _____________________.

Respondent or his/her attorney:
Name:
Address:
City, State, Zip:
Fax Number:
Designated E-mail Address(es):______
______________________________

I understand that I am swearing or affirming under oath to the truthfulness of the claims
made in this petition and that the punishment for knowingly making a false statement
includes fines and/or imprisonment.

Dated:
Signature of Petitioner
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es):____________
_____________________________________
STATE OF FLORIDA
COUNTY OF ___________________

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

{Print, type, or stamp commissioned
name of notary or deputy clerk.}
__ Personally known
__ Produced identification
Type of identification produced

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS
BELOW: [fill in all blanks] This form was prepared for the Petitioner.
This form was completed with the assistance of:
{name of individual}_____________________________________________________________ ,
{name of business}_______________________________________________________________ ,
{address} ______________________________________________________________________ ,
{city} ____________{state} __, {zip code}__________,{telephone number} ________________.

Florida Supreme Court Approved Family Law Form 12.951(a), Petition to Disestablish Paternity and/or
Terminate Child Support Obligation (03/15)
- 412 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
,
Petitioner,
and

,
Respondent.

ORDER DISESTABLISHING PATERNITY AND/OR TERMINATING
CHILD SUPPORT OBLIGATION

This cause came before the court on {date} on
{full legal name} ’s petition to
{Indicate all that apply}

__ Disestablish paternity to {child(ren)’s names and birth date(s)}

__ Terminate a child support obligation for {child(ren)’s names and birth date(s)}

The court having been fully advised in the premises FINDS all of the following:

1. Newly discovered evidence relating to the paternity of the child(ren) has come to the
petitioner’s knowledge since the initial _____ paternity determination ____ establishment
of a child support obligation.

2. Scientific tests that are generally acceptable within the scientific community to show a
probability of paternity showing that the petitioner cannot be the father of the children
were properly conducted.

3. The petitioner
{Choose only one}
__ is current on all child support payments for the child(ren).
__ has substantially complied with his child support obligation for the applicable child(ren)
and any delinquency in his child support obligation arose from his inability for just cause
to pay the delinquent child support when it became due.

4. The petitioner has not adopted the child.

Florida Supreme Court Approved Family Law Form 12.951(b), Order Disestablishing Paternity and/or
Terminating Child Support Obligation (03/15)
- 413 -
5. The child(ren) was/were not conceived by artificial insemination while the petitioner
and the child(ren)’s mother were married.

6. The petitioner did not act to prevent the biological father of the child(ren) from
asserting his paternal rights with respect to the child(ren).

7. The child(ren) was/were younger than 18 years of age when the petition was filed.

8. Since learning that he is not the biological father of the child(ren), the petitioner has not

a. married the mother of the child(ren) while known as the reputed father in accordance
with section 742.091, Florida Statutes, and voluntarily assumed the parental obligation
and duty to pay child support;
b. acknowledged paternity in a sworn statement;
c. consented to be named as the child(ren)’s biological father on the child(ren)’s birth
certificate(s);
d. voluntarily promised in writing to support the child(ren) and was required to support
the child(ren) based on that promise;
e. received written notice from any state agency or any court directing him to submit to
scientific testing which he disregarded; or
f. signed a voluntary acknowledgment of paternity as provided by section 742.10(4),
Florida Statutes.

It is therefore ORDERED AND ADJUDGED:

{Indicate all that apply}

__ Petitioner’s, {name} paternity of {name(s)
of child(ren)} ____is disestablished.

__ Petitioner’s, {name} child support
obligation to {name(s) of child(ren)} is
terminated.

DONE AND ORDERED ON ______________ in _________________________, Florida

CIRCUIT JUDGE

Florida Supreme Court Approved Family Law Form 12.951(b), Order Disestablishing Paternity and/or
Terminating Child Support Obligation (03/15)
- 414 -
I certify that a copy of the Order Disestablishing Paternity and/or Terminating Child Support
Obligation was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the
parties and any entities listed below on {date} ____________________________.

_____________________________________
{Clerk of court, designee, or Judicial Assistant}

Petitioner
Respondent
Department of Revenue
Department of Health, Office of Vital Statistics
Court depositor/State Disbursement Unit
Other

Florida Supreme Court Approved Family Law Form 12.951(b), Order Disestablishing Paternity and/or
Terminating Child Support Obligation (03/15)
- 415 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY
LAW FORM 12.960,
MOTION FOR CIVIL CONTEMPT/ENFORCEMENT (03/15)

When should this form be used?

You may use this form to ask the court to enforce a prior court order or final judgment.

What should I do next?
To initiate a civil contempt/enforcement proceeding against a party who is not complying with a
prior court order, you must file a motion with the court explaining what the party has failed to do.
This form should be typed or printed in black ink. After completing this form, you should sign it
before a notary public or deputy clerk. You should then file the original with the clerk of the circuit
court in the county where your case was filed and keep a copy for your records.

IMPORTANT INFORMATION REGARDING E-FILING

The Florida Rules of Judicial Administration now require that all petitions, pleadings, and documents
be filed electronically except in certain circumstances. Self-represented litigants may file petitions
or other pleadings or documents electronically; however, they are not required to do so. If you
choose to file your pleadings or other documents electronically, you must do so in accordance with
Florida Rule of Judicial Administration 2.525, and you must follow the procedures of the judicial
circuit in which you file. The rules and procedures should be carefully read and followed.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

To serve and receive documents by e-mail, you must designate your e-mail addresses by using the
Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family Law

Instructions for Florida Supreme Court Approved Family Law Form 12.960, Motion for Civil
Contempt/Enforcement (03/15)
- 416 -
Form 12.915, and you must provide your e-mail address on each form on which your signature
appears. Please CAREFULLY read the rules and instructions for: Certificate of Service (General),
Florida Supreme Court Approved Family Law Form 12.914; Designation of Current Mailing and E-
mail Address, Florida Supreme Court Approved Family Law Form 12.915; and Florida Rule of Judicial
Administration 2.516.

A copy of this form must be personally served by a sheriff or private process server or mailed,* e-
mailed*, or hand delivered to any other party(ies) in your case. *Please note that if notice is mailed
or e-mailed, the court in certain circumstances may not consider mailing or e-mailing, to be
adequate notice. If you want to be sure, you should have the motion personally served. This is a
technical area of the law; if you have any questions about it, you should consult a lawyer. For more
information on personal service, see the instructions for Summons: Personal Service on an
Individual, Florida Family Law Rules of Procedure Form 12.910(a).

The court will then set a hearing. You should check with the clerk of court, judicial assistant, or
family law intake staff for information on the local procedure for scheduling a hearing. Once you
know the time and date of the hearing, you will need to complete Notice of Hearing on Motion for
Contempt/Enforcement, Florida Supreme Court Approved Family Law Form 12.961, or, if applicable,
Notice of Hearing (Child Support Enforcement Hearing Officer), Florida Supreme Court Approved
Family Law Form 12.921, or [Notice of Hearing Before] General Magistrate, Florida Family Law
Rules of Procedure Form 12.920[(c)], which will specify a time and place for a hearing on the issue.
A copy of this form must be mailed, e-mailed, or hand delivered to the other party. Again, if notice
is mailed, the court in certain circumstances may not consider mailing or e-mailing to be adequate
notice. If you want to be sure, you should have the notice personally served. This is a technical area
of the law; if you have any questions about it, you should consult a lawyer. For more information on
personal service, see the instructions for Summons: Personal Service on an Individual, Florida
Family Law Rules of Procedure Form 12.910(a).

At the hearing, as in any other civil proceeding, you, as the moving party, will have the burden of
proving the other party has not obeyed a prior court order. Once noncompliance is established, the
other party will have an opportunity to show an inability to comply with the prior court order. If he
or she is unable to do so, the judge may find the other party to be in contempt. If so, the judge may
order appropriate sanctions to compel compliance by the other party, including jail, payment of
attorneys’ fees, suit money, or costs, and coercive or compensatory fines, and may order any other
relief permitted by law.

Where can I look for more information?
Before proceeding, you should read “General Information for Self-Represented Litigants” found at
the beginning of these forms. See also section 61.14, Florida Statutes and rule 12.615, Florida
Family Law Rules of Procedure.

Instructions for Florida Supreme Court Approved Family Law Form 12.960, Motion for Civil
Contempt/Enforcement (03/15)
- 417 -
Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of Disclosure from Nonlawyer, Florida Family Law
Rules of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill out
these forms also must put his or her name, address, and telephone number on the bottom of the
last page of every form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.960, Motion for Civil
Contempt/Enforcement (03/15)
- 418 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
,
Petitioner,

and

,
Respondent.

MOTION FOR CIVIL CONTEMPT/ENFORCEMENT

_____ Petitioner _____ Respondent requests that the Court enter an order of civil
contempt/enforcement against _____ Petitioner _____ Respondent in this case because:
1. A final judgment or order {title of final judgment or order}__________________________
in this case was entered on {date} , by {court, city, and state}
.
_____Please indicate here if the judgment or order is not from this Court and attach a copy.

2. This order of the Court required the other party in this case to do or not do the following:
{Explain what the other party was ordered to do or not do.} __________________________

______Please indicate here if additional pages are attached.

3. The other party in this case has willfully failed to comply with this order of the Court: {Explain
what the other party has or has not done.} _________________________________

_______ Please indicate here if additional pages are attached.

4. I respectfully request that the Court issue an order holding the above-named person in civil
contempt, if appropriate, and/or providing the following relief:

Florida Supreme Court Approved Family Law Form 12.960, Motion for Civil Contempt/Enforcement (03/15)
- 419 -
a. _____enforcing or compelling compliance with the prior order or judgment;
b. _____awarding a monetary judgment;
c. _____if a monetary judgment was included in the prior order, issuing a writ of execution
or garnishment or other appropriate process;
d. _____awarding prejudgment interest;
e. _____requiring the other party to pay costs and fees in connection with this motion;
f. _____if the other party is found to be in civil contempt, ordering a compensatory fine;
g. _____if the other party is found to be in civil contempt, ordering a coercive fine;
h. _____if the other party is found to be in civil contempt, ordering incarceration of the
other party with a purge;
i. _____issuing a writ of possession for real property, writ for possession of personal
property, or other appropriate writ;
j. _____issuing a writ of bodily attachment if the other party fails to appear at the hearing
set on this motion;
k. _____requiring the other party to make payments through the central governmental
depository;
l. _____requiring the support payments to be automatically deducted from the other
party’s income or funds;
m. _____requiring the other party to seek employment;
n. _____awarding make-up time-sharing with minor child(ren) as follows {explain}:

; and
o. _____awarding other relief {explain}: __________________________________

I certify that a copy of this document was: ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-
delivered to the person(s) listed below on {date} ____________________.

Other party or his/her attorney:
Name:
Address:
City, State, Zip: ________
Fax Number:
Designated E-mail Address(es):_____________
_____________________________________

Florida Supreme Court Approved Family Law Form 12.960, Motion for Civil Contempt/Enforcement (03/15)
- 420 -
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
motion and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.

Dated: _______________________

Signature of Party
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es):________________
________________________________________

STATE OF FLORIDA
COUNTY OF ________________________

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

[Print, type, or stamp commissioned name of notary or
clerk.]

__ Personally known
__ Produced identification
Type of identification produced ______________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent.
This form was completed with the assistance of:
{name of individual} _________________________________________________________________ ,
{name of business} __________________________________________________________________ ,
{address} ___________________________________________________________________________,
{city} ________________,{state} _____, {zip code} __________,{telephone number} _____________.

Florida Supreme Court Approved Family Law Form 12.960, Motion for Civil Contempt/Enforcement (03/15)
- 421 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.961
NOTICE OF HEARING ON MOTION FOR CONTEMPT/ENFORCEMENT
(03/15)

When should this form be used?

Use this form anytime you have set a hearing on a Motion for Contempt/Enforcement, Florida Supreme
Court Approved Family Law Form 12.960, for a support matter under rule 12.615, Florida Family Law
Rules of Procedure. Before you fill out this form, you should coordinate a hearing time and date with
the judge or hearing officer and the other party. If the Department of Revenue is a party to the case,
you may need to schedule your hearing time with the attorney for the Department of Revenue.

If your case is to be heard by a child support enforcement hearing officer, the following information
applies: A child support enforcement hearing officer is an attorney who has been appointed by
administrative order of the court to take testimony and recommend decisions in cases involving the
establishment, enforcement, and/or modification of child support, and the enforcement of alimony in
conjunction with an ongoing child support arrearage order. If your case only involves issues pertaining
to child support, you cannot object to the referral of your case to a hearing officer. If your case is going
to be heard by a general magistrate, you should use Notice of Hearing Before General Magistrate,
Florida Family Law Rules of Procedure Form 12.920(c).

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?

A copy of this form must be personally served by a sheriff or private process server, mailed*, e-mailed*,
or hand-delivered to any other party(ies) in your case. Please note that if notice is mailed, the court in
certain circumstances may not consider mailing to be adequate notice. This is a technical area of the

Instructions for Florida Supreme Court Approved Family Law Form 12.961, Notice of Hearing on Motion for
Contempt /Enforcement (03/15)
- 422 -
law; if you have any questions about it, you should consult a lawyer. For more information on personal
service, see the instructions for Summons: Personal Service on an Individual, Florida Family Law Rules
of Procedure Form 12.910(a).

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Where can I look for more information?

Before proceeding, you should read General Information for Self-Represented Litigants found at the
beginning of these forms. For further information, see rules 12.615 and 12.941, Florida Family Law
Rules of Procedure.
Special notes

An attorney who has been appointed by the court to serve as a child support enforcement hearing
officer can also be appointed to serve as a general magistrate. If your case involves only child support
issues, your case properly may be referred to a general magistrate acting as a child support enforcement
hearing officer.

Instructions for Florida Supreme Court Approved Family Law Form 12.961, Notice of Hearing on Motion for
Contempt /Enforcement (03/15)
- 423 -
IN THE CIRCUIT COURT OF THE ____________________ JUDICIAL CIRCUIT,
IN AND FOR ____________________ COUNTY, FLORIDA

Case No.: __________________________
Division: ___________________________

______________________________________,
Petitioner,

and

______________________________________,
Respondent.

NOTICE OF HEARING ON MOTION FOR
CONTEMPT/ENFORCEMENT IN SUPPORT MATTERS
(RULE 12.615)

TO: {name of other party} ____________________________________________________________

There will be a hearing before ________________________________ {name of judge or hearing officer},
on {date}________________, at {time} ______ m., in room _______ of the
_________________________
Courthouse, on the _____ Petitioner's _____ Respondent's Motion for Contempt in Support Matters.
____hour(s)/____ minutes have been reserved for this hearing.

FAILURE TO APPEAR AT THE HEARING MAY RESULT IN THE COURT ISSUING A WRIT OF BODILY
ATTACHMENT FOR YOUR ARREST. IF YOU ARE ARRESTED, YOU MAY BE HELD IN JAIL UP TO 48 HOURS
BEFORE A HEARING IS HELD.

This part is to be filled out by the court or to be filled in with information obtained from the court:

Florida Supreme Court Approved Family Law Form 12.961, Notice of Hearing on Motion for Contempt/
Enforcement (03/15)
- 424 -
{identify applicable court personnel by name, address, and telephone number }
at least 7 days before your scheduled court appearance, or immediately upon
receiving this notification if the time before the scheduled appearance is less
than 7 days; if you are hearing or voice impaired, call 711.

If you are represented by an attorney or plan to retain an attorney for this matter, you should notify the
attorney of this hearing.

If this matter is resolved, the moving party shall contact the judge or hearing officer’s office to cancel
this hearing.
I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand
delivered to the person(s) listed below on {date} ______________.

Dated: _____________________

_____________________________________________
Signature of Party
Printed Name: _________________________________
Address: ______________________________________
City, State, Zip: _________________________________
Telephone Number: _____________________________
Fax Number: ___________________________________
Designated E-mail Address(es):____________________
_____________________________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent.
This form was completed with the assistance of:
{name of individual} __________________________________________________________________ ,
{name of business} _____________________________________________________________________,
{address}_____________________________________________________________________________,
{city} ______________, {state} ____, {zip code}_________, {telephone number} ____________________.

Florida Supreme Court Approved Family Law Form 12.961, Notice of Hearing on Motion for Contempt/
Enforcement (03/15)
- 425 -
IN THE CIRCUIT COURT OF THE _______________ JUDICIAL CIRCUIT,
IN AND FOR __________________COUNTY, FLORIDA

Case No:__________________________
Division: __________________________
____________________________,
Petitioner,
and
____________________________,
Respondent.

WRIT OF BODILY ATTACHMENT
(Child Support)

TO ALL AND SINGULAR SHERIFFS AND OTHER AUTHORIZED LAW ENFORCEMENT PERSONNEL OF
THE STATE OF FLORIDA

YOU ARE ORDERED to take into custody __________________________________________
{see attached Description Sheet} and confine him/her in the county jail. The individual failed to
appear before the court as ordered, failed to appear at a properly noticed hearing, and/or
failed to comply with the previous order of the court which is attached and incorporated
herein.

Service of this writ may be made on any day of the week and any time of the night or day,
including Sunday and holidays.

YOU ARE FURTHER DIRECTED to bring this person before the court within 48 hours of execution
of the writ for a hearing to determine the individual’s present ability to pay support and, if so,
whether the failure to pay such support is willful, pursuant to Rule 12.615(c)(2)(B), Florida
Family Law Rules of Procedure.

NOTICE OF EXECUTION OF THIS WRIT SHALL IMMEDIATELY BE GIVEN TO THE FOLLOWING:
{Indicate all that apply}
_____ The Office of the Judge/General Magistrate/Child Support Hearing Officer:
__________________________________________________________________
__________________________________________________________________
_____ Counsel for the Department of Revenue:
__________________________________________________________________
_____ Department of Revenue:
__________________________________________________________________
_____ Other:
Florida Supreme Court Approved Family Law Form 12.962, Writ of Bodily Attachment (Child Support) (03/15)
- 426 -
_________________________________________________________________

IT IS FURTHER ORDERED that the individual may purge this contempt and be immediately
released from custody at any time by the payment of the sum of $_______________________,
which includes (if applicable):
$ ___________________, to be applied to unpaid support,
$ ___________________, Sheriff’s fee,
$___________________, Department of Revenue costs.
$ ___________________, other

The court previously found in this proceeding that the individual had the ability to pay said sum.
The Sheriff, or other authorized law enforcement personnel, executing this writ or having
custody of the individual is authorized to assess and collect the actual costs associated with
service of this writ and transportation of the individual pursuant to Section 61.11(2)(a), Florida
Statutes.

PAYMENT SHALL BE MADE to the Sheriff of ___________________________ County, Florida
and shall be in the form of cash, cashier’s check, certified funds, or money order. The purge
payment, clearly marked with the individual’s name and case number, and denoted as a purge
payment shall be remitted to:
{Indicate which are applicable}:
_____ The Office of the Clerk of Circuit Court for ________________________, County,
_________________________________________________________________

_____ Other ____________________________________________________________.

The Sheriff’s office, or other authorized law enforcement personnel’s office, receiving payment
shall provide the individual with a written receipt acknowledging payment. The receipt must be
carried by the individual for a period of at least 30 days as proof of payment.

If the individual pays the purge and secures his/her release, the Sheriff shall immediately notify:
_____________________________________________________________________________.

THIS ORDER SUPERSEDES ALL PRIOR CONFLICTING ORDERS.

DONE AND ORDERED in ____________ County, Florida this _____day of ___________, 20____.

________________________________
CIRCUIT JUDGE
Florida Supreme Court Approved Family Law Form 12.962, Writ of Bodily Attachment (Child Support) (03/15)
- 427 -
I certify that a copy of this {name of document}____________________________________________
was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the parties or entities listed
below on {date}___________________________.

by___________________________________
{Clerk of court or designee}

Petitioner (or his/her attorney)
Respondent (or his/her attorney)
Department of Revenue
Sheriff of ____________________County
Other:____________________________

Florida Supreme Court Approved Family Law Form 12.962, Writ of Bodily Attachment (Child Support) (03/15)
- 428 -
DESCRIPTION SHEET
NAME: _________________________________________ DATE OF BIRTH: _______________
OTHER NAMES THE INDIVIDUAL GOES BY (ALIASES OR NICKNAMES): ______________________
______________________________________________________________________________
ADDRESS: _____________________________________________________________________
ALTERNATE ADDRESS: ___________________________________________________________
TELEPHONE: _________________________ ALTERNATE PHONE: _________________________
SOCIAL SECURITY NUMBER: ______________________ GENDER:________ RACE: ________
HEIGHT: _____________ WEIGHT: ____________ EYE COLOR: ____________
HAIR COLOR, LENGTH, STYLE: _____________________________________________________
DISTINGUISHING MARKS, SCARS, TATTOOS: _____________________________________
OTHER CHARACTERISTICS: ________________________________________________________
EMPLOYER: ____________________________________ EMPLOYER PHONE: _______________
EMPLOYER ADDRESS: ____________________________________________________________
VEHICLE (MAKE/MODEL): ________________________________________________________
FLORIDA DRIVER’S LICENSE NUMBER: _______________________________________________

Please use the space below for any additional information you would like to provide.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Florida Supreme Court Approved Family Law Form 12.962, Writ of Bodily Attachment (Child Support) (03/15)
- 429 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.970(a)
PETITION FOR TEMPORARY CUSTODY BY EXTENDED FAMILY (03/15)
When should this form be used?

This form should be used by an extended family member to obtain temporary custody of a child or
children pursuant to Chapter 751, Florida Statutes. This form should not be used if you are a parent
seeking to establish parental responsibility or time-sharing with a child or children.

An Extended Family Member is:
A relative of a minor child within the third degree by blood or marriage to the parent;
OR
The stepparent of a minor child if the stepparent is currently married to the parent of the child and is
not a party in a pending dissolution, separate maintenance, domestic violence, or other civil or criminal
proceeding in any court of competent jurisdiction involving one or both of the child(ren)’s parents as an
adverse party.

You may file a Petition for Temporary Custody if:
You have the signed, notarized consents of the child(ren)’s legal parents;
OR
You are an extended family member who is caring full time for the child(ren) in the role of a substitute
parent and with whom the child(ren) is (are) presently living.

If one of the minor child(ren)’s parents objects to the Petition, the court shall grant the Petition only
upon a finding, by clear and convincing evidence, that the child(ren)’s parent or parents are unfit to
provide for the care and control of the child(ren). In determining that a parent is unfit, the court must
find that the parent has abused, abandoned, or neglected the child(ren), as defined in Chapter 39,
Florida Statutes. If you do not have the parents’ consents you should consult a family law attorney
before you file your papers.

If you do not meet the qualifications above, you should talk to an attorney about other options. You
may also report any suspected abuse, abandonment, or neglect to the appropriate authorities.

IMPORTANT INFORMATION REGARDING E-FILING

The Florida Rules of Judicial Administration now require that all petitions, pleadings, and documents be
filed electronically except in certain circumstances. Self-represented litigants may file petitions or other
pleadings or documents electronically; however, they are not required to do so. If you choose to file
your pleadings or other documents electronically, you must do so in accordance with Florida Rule of
Judicial Administration 2.525, and you must follow the procedures of the judicial circuit in which you file.
Instructions for Florida Supreme Court Approved Family Law Form 12.970(a), Petition for Temporary Custody By
Extended Family (03/15)
- 430 -
The rules and procedures should be carefully read and followed.
IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

What should I do next?

IF YOU HAVE SIGNED AND NOTARIZED WAIVERS OF SERVICE OF PROCESS AND CONSENTS from the
child(ren)’s mother and father, and the case is uncontested, you may call the clerk, family law intake
staff, or judicial assistant, to set a final hearing. You must notify the child(ren)’s parents of the hearing
by using a Notice of Hearing (General), Florida Supreme Court Approved Family Law Form 12.923, or
other appropriate notice of hearing form.

If one of the parents is deceased, you must file a certified copy of the proof of death.

IF YOU DO NOT HAVE SIGNED AND NOTARIZED WAIVERS OF SERVICE OF PROCESS AND CONSENTS from
the child(ren)’s parents, you must properly notify the parents of the petition. If you know where he or
she lives, you should use personal service. If you absolutely do not know where he or she lives after
conducting a diligent search, you may use constructive service. You must complete all of the searches
listed in the Affidavit of Diligent Search and Inquiry, Florida Family Law Rules of Procedure Form
12.913(b), and file the form with the clerk. You should seek legal advice on constructive service as this is
a complicated area of the law. If the identity of one parent is unknown, you will need to seek legal
advice to determine the proper way to serve an unknown parent. For more information, see Chapter 49,
Florida Statutes.

If personal service is used, the parents have 20 days to answer after being served with your petition.
Your case will generally proceed in one of the following ways:

DEFAULT... If after 20 days, no answer has been filed, you may file a Motion for Default, Florida
Supreme Court Approved Family Law Form 12.922(a), with the clerk of court. You must file a Notice for
Instructions for Florida Supreme Court Approved Family Law Form 12.970(a), Petition for Temporary Custody By
Extended Family (03/15)
- 431 -
Trial, Florida Supreme Court Approved Family Law Form 12.924. Then, if you have filed all of the
required papers, you may call the clerk, family law intake staff, or judicial assistant, to set a final
hearing. You must notify the child(ren)’s parents of the hearing by using a Notice of Hearing (General),
Florida Supreme Court Approved Family Law Form 12.923, or other appropriate notice of hearing form.

CONTESTED... If either parent files an answer which disagrees with or denies anything in your petition,
and you are unable to settle the disputed issues, you must file a Notice for Trial, Florida Supreme Court
Approved Family Law Form 12.924, to request a final hearing. Some circuits may require the completion
of mediation before a final hearing may be set. You should contact the clerk, family law intake staff, or
judicial assistant for instructions on how to set your case for trial (final hearing).

At any time, either or both of the child(ren)’s parents may petition the court to modify or terminate the
order granting temporary custody. The court shall terminate the order upon a finding that the parent is
a fit parent, or by the consent of the parties. The court may modify an order granting temporary
custody if the parties consent or if the modification is in the best interest of the child(ren).

Where can I look for more information?

Special Notes. . .

If you do not have the money to pay the filing fee, you may obtain an application for Determination of
Civil Indigent Status, fill it out, and the clerk will determine whether you are eligible to have filing fees
deferred.

With this petition, you must file the following and provide a copy to the other party:
 Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida Supreme
Court Approved Family Law Form 12.902(d).
 Notice of Related Cases, Florida Family Law Rules of Procedure Form 12.900(h).
 Family Court Cover Sheet, Florida Family Law Rules of Procedure Form 12.928.
 Non-Military Affidavit, Florida Supreme Court Approved Family Law Form 12.912(b). (Required
only for obtaining a default on petitions that have been personally or constructively served. Not
required if both parents have signed a waiver and consent)

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill out these forms
must also put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.970(a), Petition for Temporary Custody By
Extended Family (03/15)
- 432 -
IN THE CIRCUIT COURT OF THE ____________ JUDICIAL CIRCUIT,
IN AND FOR ___________________________ COUNTY, FLORIDA

Case No: _______________________
Division: _______________________

__________________________________,
Petitioner,
and
__________________________________,
Respondent/Mother,

__________________________________,
Respondent/Father.

PETITION FOR TEMPORARY CUSTODY BY EXTENDED FAMILY

Petitioner, {full legal name} _________________________________, being sworn, certifies that the
following information is true:

1. This is an action for temporary custody pursuant to Chapter 751, Florida Statutes.

2. Petitioner requests temporary custody of the following minor child(ren):
Name Date of Birth Current Address
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

3. Petitioner completed a Uniform Child Custody Jurisdiction and Enforcement Act Affidavit,
Florida Supreme Court Approved Family Law Form 12.902(d), which was filed with this Petition.
The affidavit includes the names and current addresses of the persons with whom the child(ren)
has(have) lived during the past 5 years, the places where the child(ren) has(have) lived during
the past 5 years, and information concerning any custody proceeding in this or any other state
with respect to the child(ren). If the Affidavit is not completely filled out, signed under oath,
and filed with the Petition, the case may be dismissed without hearing.

4. Petitioner is an extended family member who is: {Choose one only}
_____ Related to the minor child(ren) within the third degree by blood or marriage to a parent;
OR
_____ The stepparent of the minor child(ren), is married to the ____ Mother ____ Father and
is not a party in a pending dissolution, separate maintenance, domestic violence, or other civil or
criminal proceeding in any court of competent jurisdiction involving one or both of the
child(ren)’s parents as an adverse party.
Florida Supreme Court Approved Family Law Form 12.970(a), Petition for Temporary Custody By Extended Family
(03/15)
- 433 -
5. Petitioner’s relationship to the minor child(ren) is: ____________________________________.

6. The residence and post office address of the Petitioner is: ______________________________
____________________________________________________________________________ .

7. Petitioner is a proper person to be awarded temporary custody because: {Choose one only}
____ Petitioner has the signed, notarized consent from both of the child(ren)’s legal parents;
OR
____ Petitioner is caring full time for the child(ren) in the role of a substitute parent and the
child(ren) currently live with the Petitioner.

If Petitioner does not have the signed consents from both parents or is not caring for the
child(ren) full time as a substitute parent, Petitioner cannot obtain temporary custody under
Chapter 751, Florida Statutes. Petitioner should consult an attorney about other options.

8. The legal mother of the child(ren) is ____________________________________, whose current
address is: _____________________________________________________________________.

9. The legal father of the child(ren) is ______________________________________, whose
current address is: ___________________________________________________________.

10. The Consents of ______Father and/or _________ Mother is/are attached to the Petition.
OR
{If Applicable} The Consent of the _________________ is not attached because that parent is
deceased. A certified copy of the proof of death is attached.
OR
Consent has NOT been obtained from the parents. The specific acts or omissions of the parents
which demonstrate that the parents have abused, abandoned, or neglected the child(ren) as
defined in Chapter 39, Florida Statutes are: (attach additional sheets if necessary) __________
_____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ .

11. Petitioner requests temporary custody be granted for the following period of time:___________
___________________________________________________________________________ .
The reasons that support this request are: ___________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ .

12. It is in the best interests of the child(ren) that the Petitioner have temporary custody of the
child(ren) for the following reasons: _______________________________________________
______________________________________________________________________________
______________________________________________________________________________

Florida Supreme Court Approved Family Law Form 12.970(a), Petition for Temporary Custody By Extended Family
(03/15)
- 434 -
______________________________________________________________________________ .

Florida Supreme Court Approved Family Law Form 12.970(a), Petition for Temporary Custody By Extended Family
(03/15)
- 435 -
13. ORDER OF PROTECTION
_____ Petitioner IS NOT aware of any temporary or permanent order for protection entered
on behalf of or against either parent, the Petitioner, or the child(ren) in Florida or any
other jurisdiction.
OR
_____ Petitioner IS aware of the following temporary or permanent orders for protection
entered on behalf of or against either parent, the Petitioner, or the child(ren) in Florida
or any other jurisdiction. The court entering the order and the case number is: _______
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________.

14. TEMPORARY OR PERMANENT CHILD SUPPORT ORDERS
_____ Petitioner IS NOT aware of any temporary or permanent orders for child support for the
minor child(ren).
OR
_____ Petitioner IS aware of the following temporary or permanent order for child support for
the minor child(ren). The court entering the order and the case number is:_________
_______________________________________________________________________
________________________________________________________________________
_______________________________________________________________________ .

15. CHILD SUPPORT (Choose one only}
(You must have proof or waiver of service of process upon the parent(s) or a Waiver of Service
of Process and Consent for the court to consider an award for child support)

_____ Petitioner requests the court to order the parents to pay child support.
_____ Petitioner requests the court to redirect all or part of Mother’s and/or Father’s existing
child support obligation to the Petitioner.
_____ Petitioner requests the court to redirect all or part of Mother’s and/or Father’s existing
child support obligation to the Petitioner, and to award the Petitioner child support
arrearages.

16. Petitioner ____ requests _____ does not request that the court establish reasonable visitation
or a time-sharing schedule with the parents.

17. Other
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________.

WHEREFORE, Petitioner requests that this Court grant the Petitioner temporary custody of the child(ren)
subject to this proceeding; award the Petitioner other relief as requested; and award any other relief

Florida Supreme Court Approved Family Law Form 12.970(a), Petition for Temporary Custody By Extended Family
(03/15)
- 436 -
that the Court deems necessary.

Florida Supreme Court Approved Family Law Form 12.970(a), Petition for Temporary Custody By Extended Family
(03/15)
- 437 -
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
petition and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.

Dated:_____________________________ _______________________________________
Signature of Petitioner

Printed Name: __________________________
Address: __________________________________
City, State, Zip Code: ________________________
Telephone Number: _________________________
Number: _______________________________
E-Mail Address(es):__________________
__________________________________________

STATE OF FLORIDA
COUNTY OF __________________________________

Sworn to or affirmed and signed before me on _____________ by ___________________________.

_______________________________________
NOTARY PUBLIC OR DEPUTY CLERK

________________________________________
{Print, type, or stamp commissioned name of notary or
deputy clerk.}
____ Personally known
____ Produced identification
Type of identification produced _________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the Petitioner.
This form was completed with the assistance of:
{name of individual} ____________________________________________________________ ,
{name of business} _____________________________________________________________ ,
{address} ______________________________________________________________________ ,
{city} __________________, {state} ____,{zip code} ___________, {telephone number} _________.

Florida Supreme Court Approved Family Law Form 12.970(a), Petition for Temporary Custody By Extended Family
(03/15)
- 438 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.970(b)
PETITION FOR CONCURRENT CUSTODY BY EXPENDED FAMILY (03/15)

When should this form be used?
This form should be used by an extended family member to obtain concurrent custody of a child or
children pursuant to Chapter 751, Florida Statutes. This form should not be used if you are a parent
seeking to establish parental responsibility or time-sharing with a child or children. “Concurrent
custody” means that an eligible extended family member is awarded custodial rights to care for a child
or children concurrently with the child(ren)’s parent or parents.

You may file a Petition for Concurrent Custody if:
You have the signed, notarized consents of the child(ren)’s legal parents;
OR
You are an extended family member who is caring full time for the child(ren) in the role of a substitute
parent and with whom the child(ren) is (are) presently living.

In addition, you must currently have physical custody of the child(ren) and have had physical custody of
the child(ren) for at least 10 days in any 30-day period within the last 12 months; and not have signed,
written documentation from a parent which is sufficient to enable you to do all the things necessary to
care for the child(ren).

If you do not meet the qualifications above, you should talk to an attorney about other options. You
may also report any suspected abuse, abandonment, or neglect to the appropriate authorities.

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?
IF YOU HAVE SIGNED AND NOTARIZED WAIVERS OF SERVICE OF PROCESS AND CONSENTS from the
child(ren)’s mother and father, you may call the clerk, family law intake staff, or judicial assistant, to set
a final hearing. You must notify the child(ren)’s parents of the hearing by using a Notice of Hearing
(General), Florida Supreme Court Approved Family Law Form 12.923, or other appropriate notice of
hearing form.

If one of the parents is deceased, you must file a certified copy of the proof of death.

If one of the minor child(ren)’s parents objects to the Petition for Concurrent Custody in writing, the
court may not grant the petition even if the other parent consents, in writing, to the entry of the order.
If a parent objects, you have the option of converting the Petition to a Petition for Temporary Custody
by Extended Family, Florida Supreme Court Approved Family Law Form 12.970(a). If the Petition is not
converted into a Petition for Temporary Custody by Extended Family, it shall be dismissed without
prejudice.

At any time, the Petitioner or either or both of the child(ren)’s parents may move the court to terminate
the order granting concurrent custody. The court shall terminate the order upon a finding that either or
both of the child(ren)’s parents objects to the order. The fact that the order for concurrent custody has
been terminated does not preclude any person who is otherwise eligible to petition for temporary
custody from filing such petition.

Where can I look for more information?
Before proceeding, you should read General Information for Self-Represented Litigants found at the
Instructions for Florida Supreme Court Approved Family Law Form 12.970(b), Petition for Concurrent Custody By
Extended Family (03/15)
- 440 -
beginning of these forms. The words that are in bold underline in these instructions are defined there.
For further information, see Chapter 751 and Chapter 39, Florida Statutes.

Special Notes. . .

With this petition, you must file the following and provide a copy to the other party:
 Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida Supreme
Court Approved Family Law Form 12.902(d).
 Notice of Related Cases, Florida Family Law Rules of Procedure Form 12.900(h).
 Family Court Cover Sheet, Florida Family Law Rules of Procedure Form 12.928.
 Non-Military Affidavit, Florida Supreme Court Approved Family Law Form 12.912(b). (Required
only for obtaining a default on petitions that have been personally or constructively served. Not
required if both parents have signed a waiver and consent.)

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill out these forms
must also put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.970(b), Petition for Concurrent Custody By
Extended Family (03/15)
- 441 -
IN THE CIRCUIT COURT OF THE _______________ JUDICIAL CIRCUIT,
IN AND FOR _______________________________ COUNTY, FLORIDA

Case No: _______________________
Division: _______________________

__________________________________,
Petitioner,
and
__________________________________,
Respondent/Mother,

__________________________________,
Respondent/Father.

PETITION FOR CONCURRENT CUSTODY BY EXTENDED FAMILY
Petitioner, {full legal name} _________________________________, being sworn, certifies that the
following information is true:

1. This is an action for concurrent custody pursuant to Chapter 751, Florida Statutes.

2. Petitioner requests concurrent custody of the following minor child(ren):
Name Date of Birth Current Address
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

3. Petitioner completed a Uniform Child Custody Jurisdiction and Enforcement Act Affidavit,
Florida Supreme Court Approved Family Law Form 12.902(d), which was filed with this Petition.
The affidavit includes the names and current addresses of the persons with whom the child(ren)
has (have) lived during the past 5 years, the places where the child(ren) has(have) lived during
the past 5 years, and information concerning any custody proceeding in this or any other state
with respect to the child(ren). If the Affidavit is not completely filled out, signed under oath,
and filed with the Petition, the case may be dismissed without a hearing.

Florida Supreme Court Approved Family Law Form 12.970(b), Petition for Concurrent Custody By Extended Family
(03/15)
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5. Petitioner’s relationship to the minor child(ren) is: ____________________________________.
6. The residence and post office address of the Petitioner is: ______________________________
______________________________________________________________________________.

7. The legal mother of the child(ren) is _____________________________________, whose
current address is:__________________________________________________________ .

8. The legal father of the child(ren) is ______________________________________, whose
current address is: ______________________________________________________________.

9. Petitioner currently has physical custody of the child(ren) and has had physical custody of the
child(ren) for at least 10 days in any 30-day period within the last 12 months. Detail the time
periods during the past 12 months when the child(ren) have resided with the Petitioner:
______________________________________________________________________________
_____________________________________________________________________________
______________________________________________________________________________.

10. Petitioner does not have signed, written documentation from a parent which is sufficient to
enable the Petitioner to do all of the things necessary to care for the child(ren).

11. {If applicable} Describe the type of documents, if any, provided by the parent or parents which
enables the Petitioner to act on behalf of the child(ren): ________________________________
______________________________________________________________________________.
These documents are attached to this Petition as Exhibit ________.

12. Petitioner is unable to obtain or undertake the following services or actions without an order of
custody:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.

13. The Consents of ______Father and/or _________ Mother is/are attached to the Petition.
OR
{If applicable} The Consent of the _________________ is not attached because that parent is
deceased. A certified copy of the proof of death is attached.

14. Petitioner requests concurrent custody be granted for the following period of
time:________________________________________________________________________.
The reasons that support this request are: ___________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.

15. It is in the best interests of the child(ren) that the Petitioner have concurrent custody of the
child(ren) for the following reasons: ________________________________________________

Florida Supreme Court Approved Family Law Form 12.970(b), Petition for Concurrent Custody By Extended Family
(03/15)
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______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________.
16. ORDER OF PROTECTION
____ Petitioner IS NOT aware of any temporary or permanent order for protection entered
on behalf of or against either parent, the Petitioner, or the child(ren) in Florida or any
other jurisdiction.
OR
____ Petitioner IS aware of the following temporary or permanent orders for protection
entered on behalf of or against either parent, the Petitioner, or the child(ren) in Florida
or any other jurisdiction. The court entering the order and the case number is: _______
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________.

17. TEMPORARY OR PERMANENT CHILD SUPPORT ORDERS
____ Petitioner IS NOT aware of any temporary or permanent orders for child support for the
minor child(ren).
OR
____ Petitioner IS aware of the following temporary or permanent order for child support for
the minor child(ren). The court entering the order and the case number is:__________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________.

18. CHILD SUPPORT (If Petitioner is seeking child support) {Choose one only}
(You must have proof of service upon or waiver of process by the parent(s) or a Waiver of
Service of Process and Consent for the court to consider an award for child support)

____ Petitioner requests the court to order the parents to pay child support.
____ Petitioner requests the court to redirect all or part of Mother’s and/or Father’s existing
child support obligation to the Petitioner.
____ Petitioner requests the court to redirect all or part of Mother’s and/or Father’s existing
child support obligation to the Petitioner, and to award the Petitioner child support
arrearages.

19. Petitioner ____ requests _____ does not request that the court establish reasonable visitation
or a time-sharing schedule with the parents.

20. Other _______________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________

WHEREFORE, Petitioner requests that this Court grant the Petitioner concurrent custody of the
child(ren) subject to this proceeding; award the Petitioner other relief as requested; and award any

Florida Supreme Court Approved Family Law Form 12.970(b), Petition for Concurrent Custody By Extended Family
(03/15)
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other relief that the Court deems necessary.

Florida Supreme Court Approved Family Law Form 12.970(b), Petition for Concurrent Custody By Extended Family
(03/15)
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I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
petition and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.

Dated: _____________________________ _________________________________________
Signature of Petitioner

Printed Name: _____________________________
Address: __________________________________
City, State, Zip Code: ________________________
Telephone Number: _________________________
Fax Number: _______________________________
Designated E-mail Address(es):_________________
_________________________________________

STATE OF FLORIDA
COUNTY OF __________________________________

Sworn to or affirmed and signed before me on _______________ by ___________________________.

_______________________________________
NOTARY PUBLIC OR DEPUTY CLERK

________________________________________
Print, type, or stamp commissioned name of notary or
deputy clerk.

____ Personally known
____ Produced identification
Type of identification produced _________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the Petitioner.
This form was completed with the assistance of:
{name of individual} ____________________________________________________________ ,
{name of business} ____________________________________________________________ ,
{address} ______________________________________________________________________ ,
{city} _________________, {state} _____, {zip code}__________, {telephone number} ______________ .

Florida Supreme Court Approved Family Law Form 12.970(b), Petition for Concurrent Custody By Extended Family
(03/15)
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INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.970(c),
WAIVER OF SERVICE OF PROCESS AND CONSENT FOR TEMPORARY
CUSTODY BY EXTENDED FAMILY (03/15)
This form is to be completed and signed by a parent who agrees to grant temporary custody of a minor
child or child(ren) to an extended family member and agrees to waive service of process. Service of
process occurs when a summons and a copy of the petition (or other pleading) that has been filed with
the court are delivered by a deputy or private process server.

This form should be typed or printed in black ink. After completing this form, you should sign the form
before a notary public or deputy clerk. You should file the original with the clerk of the circuit court in
the county where the Petition for Temporary Custody by Extended Family, Florida Supreme Court
Approved Family Law Form 12.970(a) is filed and keep a copy for your records.

IMPORTANT INFORMATION REGARDING E-FILING

Special notes. . .
Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill out these forms
must also put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.970(c), Waiver of Service of Process and
Consent for Temporary Custody By Extended Family (03/15)
- 447 -
IN THE CIRCUIT COURT OF THE _______________ JUDICIAL CIRCUIT,
IN AND FOR _______________________________ COUNTY, FLORIDA

Case No: _______________________
Division: _______________________

__________________________________,
Petitioner,
and
__________________________________,
Respondent/Mother,

__________________________________,
Respondent/Father.

WAIVER OF SERVICE OF PROCESS AND CONSENT FOR TEMPORARY
CUSTODY BY EXTENDED FAMILY

I, _____________________________________________, the legal _____ Mother ____ Father of
{child(ren)’s name)s)} _____________________________________________, having received a copy of
the Petition for Temporary Custody by Extended Family filed herein and waived service of process, freely
and voluntarily consent to the Petition filed by: {Petitioner’s Name} __________________________.

I realize that by signing this document, I am consenting to the Petitioner having temporary legal custody
of the minor child(ren) and that such temporary custody is in the best interest of the child(ren). Upon
entry of an Order, the Petitioner shall be able to:

1. Consent to all necessary and reasonable medical and dental care for the child(ren), including
nonemergency surgery and psychiatric care;

2. Secure copies of the child(ren)’s records, held by third parties, that are necessary for the
care of the child(ren), including, but not limited to:
a. Medical, dental, and psychiatric records;
b. Birth Certificates and other records, and
c. Educational records.

3. Enroll the child(ren) in school and grant or withhold consent for the child(ren) to be tested
or placed in special school programs, including exceptional education; and

4. Do all other things necessary for the care of the child(ren).

Florida Supreme Court Approved Family Law Form 12.970(c), Waiver of Service of Process and Consent for
Temporary Custody By Extended Family (03/15)
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I realize that the custody of my child(ren) by the Petitioner is temporary and that I may, at any time,
petition the court to return legal custody to me.

Dated: __________________ _________________________________________
Signature of Parent
Printed Name: ____________________________
Address: _________________________________
City, State, Zip Code: _______________________
Telephone Number: _______________________
Fax Number: _____________________________
Designated E-mail Address(es):_______________
________________________________________

STATE OF FLORIDA
COUNTY OF __________________________________

Sworn to or affirmed and signed before me on _______________ by ___________________________.

_______________________________________
NOTARY PUBLIC OR DEPUTY CLERK

________________________________________
Print, type, or stamp commissioned name of notary or
deputy clerk.

____ Personally known
____ Produced identification
Type of identification produced _________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the {choose only one} ( ) Petitioner ( ) Respondent.
This form was completed with the assistance of:
{name of individual} _____________________________________________________________ ,
{name of business} ________________________________________________________________ ,
{address} _________________________________________________________________________ ,
{city} _________________, {state} _____, {zip code}________, {telephone number} ______________.

Florida Supreme Court Approved Family Law Form 12.970(c), Waiver of Service of Process and Consent for
Temporary Custody By Extended Family (03/15)
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INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.970(d),
WAIVER OF SERVICE OF PROCESS AND CONSENT FOR CONCURRENT
CUSTODY BY EXTENDED FAMILY (03/15)

This form is to be completed and signed by a parent who agrees to grant concurrent custody of a minor
child or child(ren) to an extended family member and who agrees to waive service of process. Service
of process occurs when a summons and a copy of the petition (or other pleading) that has been filed
with the court are delivered by a deputy or private process server. “Concurrent custody” means that an
eligible extended family member is awarded custodial rights to care for a child or children concurrently
with the child(ren)’s parent or parents.

This form should be typed or printed in black ink. After completing this form, you should sign the form
before a notary public or deputy clerk. You should file the original with the clerk of the circuit court in
the county where the Petition for Concurrent Custody by Extended Family, Florida Supreme Court
Approved Family Law Form 12.970(b) is filed and keep a copy for your records.

IMPORTANT INFORMATION REGARDING E-FILING

Special notes. . .

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill out these forms
must also put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.970(d), Waiver of Service of Process and
Consent for Concurrent Custody By Extended Family (03/15)
- 450 -
IN THE CIRCUIT COURT OF THE _______________ JUDICIAL CIRCUIT,
IN AND FOR _______________________________ COUNTY, FLORIDA

Case No: _______________________
Division: _______________________

__________________________________,
Petitioner,
and
__________________________________,
Respondent/Mother,

__________________________________,
Respondent/Father.

WAIVER OF SERVICE OF PROCESS AND CONSENT FOR CONCURRENT
CUSTODY BY EXTENDED FAMILY

I, ____________________________________________, the legal _____ Mother _____ Father of
{child(ren)’s name(s)} _____________________________________, having received a copy of the
Petition for Concurrent Custody by Extended Family filed herein and waived service of process, freely
and voluntarily consent to the Petition filed by {Petitioner’s Name} ______________________________
.

I realize that by signing this document, I am consenting to the Petitioner having temporary concurrent
custody of the minor child(ren) and that such concurrent custody is in the best interest of the child(ren).
Upon entry of an Order, the Petitioner shall be able to:

1. Consent to all necessary and reasonable medical and dental care for the child(ren), including
nonemergency surgery and psychiatric care;

2. Secure copies of the child(ren)’s records, held by third parties, that are necessary for the care of
the child(ren), including, but not limited to:
a. Medical, dental, and psychiatric records;
b. Birth Certificates and other records, and
c. Educational records.

3. Enroll the child(ren) in school and grant or withhold consent for the child(ren) to be tested or
placed in special school programs, including exceptional education; and

4. Do all other things necessary for the care of the child(ren).

Florida Supreme Court Approved Family Law Form 12.970(d), Waiver of Service of Process and Consent for
Concurrent Custody By Extended Family (03/15)
- 451 -
I realize that the concurrent custody of my child(ren) by the Petitioner is temporary and that I may, at
any time, petition the court to return legal custody to me.

Dated: __________________________ _________________________________________
Signature of Parent

STATE OF FLORIDA
COUNTY OF __________________________

Sworn to or affirmed and signed before me on _______________ by ___________________________.

_________________________________________
NOTARY PUBLIC OR DEPUTY CLERK

_________________________________________
Print, type, or stamp commissioned name of notary or
deputy clerk.

____ Personally known
____ Produced identification
Type of identification produced _________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the {choose only one} ( ) Petitioner ( ) Respondent.
This form was completed with the assistance of:
{name of individual} _____________________________________________________________ ,
{name of business}_______________________________________________________________ ,
{address} ___________________________________________________________________________,
{city} _________________, {state} _____,{zip code}__________, {telephone number} ___________ .

Florida Supreme Court Approved Family Law Form 12.970(d), Waiver of Service of Process and Consent for
Concurrent Custody By Extended Family (03/15)
- 452 -
IN THE CIRCUIT COURT OF THE _________________________ JUDICIAL CIRCUIT
IN AND FOR __________________________ COUNTY, FLORIDA

Case No: ______________________
Division: ______________________

__________________________________,
Petitioner,
and
__________________________________,
Respondent/Mother

__________________________________,
Respondent/Father.

ORDER GRANTING PETITION FOR
TEMPORARY CUSTODY BY EXTENDED FAMILY

This case came before this Court for a hearing on a Petition for Temporary Custody by Extended
Family. The Court, having reviewed the file and heard the testimony, makes these findings of
fact and reaches these conclusions of law:

SECTION I. FINDINGS:

1. The Court has jurisdiction over the subject matter and the parties.

2. The minor child(ren) at issue in this matter are:
Name Date of Birth
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

3. The Petitioner, {full legal name} _______________________________________ is the
{extended family relationship}_____________________________________________ of
the child(ren).

4. The Mother {full legal name} _________________________________ of the child(ren):
{Choose one only}
____ Filed a Waiver and Consent
____ Was served with the petition and failed to file an Answer

Florida Supreme Court Approved Family Law Form 12.970(e), Order Granting Petition for Temporary Custody by
Extended Family (03/15)
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____ Is deceased as evidenced by: _________________________________________
____ Objected to the petition. Based upon clear and convincing evidence, the Court
finds that the Mother is unfit to provide for the care and control of the
child(ren). Specifically, the Mother has abused, abandoned, or neglected the
child(ren) as defined in Chapter 39, Florida Statutes. It is in the best interest of
the child(ren) that the Petitioner have temporary custody because: {facts in
support of finding} __________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
_________________________________________________________________ .

5. The Father {full legal name} _________________________________ of the child(ren):
{Choose one only}
____ Filed a Waiver and Consent
____ Was served with the petition and failed to file an Answer
____ Is deceased as evidenced by: _________________________________________
____ Objected to the petition. Based upon clear and convincing evidence, the Court
finds that the Father is unfit to provide for the care and control of the child(ren).
Specifically, the Father has abused, abandoned, or neglected the child(ren) as
defined in Chapter 39, Florida Statutes. It is in the best interest of the child(ren)
that the Petitioner have temporary custody because: {facts in support of finding}
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________.

6. It is in the best interest of the child(ren) for the Petitioner to have temporary custody.

SECTION II: TEMPORARY CUSTODY

1. The Petitioner, ________________________________________, is granted temporary
custody of the minor child(ren).

2. The Petitioner shall have all the rights and responsibilities of a legal parent.

3. The Petitioner is authorized to make all reasonable and necessary decisions for the
minor child(ren), including but not limited to:
a) Consent to all necessary and reasonable medical and dental care for the child(ren),
including nonemergency surgery and psychiatric care;

Florida Supreme Court Approved Family Law Form 12.970(e), Order Granting Petition for Temporary Custody by
Extended Family (03/15)
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b) Secure copies of the child(ren)’s records, held by third parties, that are necessary for
the care of the child(ren), including, but not limited to: medical, dental, and
psychiatric records; birth certificates and other records; and educational records;

c) Enroll the child(ren) in school and grant or withhold consent for the child(ren) to be
tested or placed in special school programs, including exceptional education; and

d) Do all other things necessary for the care of the child(ren).

SECTION III. TEMPORARY TIME-SHARING WITH MINOR CHILD(REN)

The parent(s) shall have: {Choose one only}
1. ____ reasonable time-sharing with the minor child(ren) as agreed to by the parties,
subject to the following limitations: __________________________________________
_______________________________________________________________________.

2. ____ the following specified time-sharing schedule: {specify days and times} _______
______________________________________________________________________.
Mother’s Temporary Time-Sharing Schedule.
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________.
Father’s Temporary Time-Sharing Schedule.
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________.

3. ____ Time-Sharing in accordance with the temporary Parenting Plan attached as
Exhibit ____.

4. The____ Mother _____ Father shall have No Contact with the minor child(ren) until
further order of the Court, due to existing conditions that are detrimental to the welfare
of the minor child(ren): {explain} ____________________________________________
_______________________________________________________________________
_______________________________________________________________________.

SECTION IV. CHILD SUPPORT

1. The Petitioner ____ did ____ did not request the establishment of child support.

2. ____ If child support is requested, the parents have received personal or substituted

Florida Supreme Court Approved Family Law Form 12.970(e), Order Granting Petition for Temporary Custody by
Extended Family (03/15)
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service of process, the petition requests an order for support of the child(ren), and there
is evidence of the parents’ ability to pay the support ordered. The _____ Mother
_____Father has the present ability to pay child support.
{Choose one only}
a. ____ The amounts in the Child Support Guidelines Worksheet, Florida Family Law
Rules of Procedure Form 12.902(e) filed by the _____Mother _____ Father are correct;
OR
b. ____ The Court makes the following findings:
The Mother’s net monthly income is $____________, (Child Support Guidelines ____%).
The Father’s net monthly income is $_____________, (Child Support Guidelines ____%)
Monthly child care costs are $_________________.
Monthly health/dental insurance costs are $_____________.
OR
c. The ____ Mother _____ Father is currently ordered to pay child support to the other
parent in the amount of $_____________ per _______________ as established in the
case of {style of case and number} __________________________________________
_______________________________________________________________________.
_____ All of the child support or _____ a portion of the child support in the amount of
$____________ shall be redirected to the Petitioner.

3. Amount
a) Father’s Obligation
The Father shall be obligated to pay child support at the rate of $___________ per
month for the ______ children {total number of parties’ minor or dependent
children} commencing ___________________________ {month, day, year} and
terminating ________________________ {month, day, year}.
Child support shall be paid in the amount of $___________ per ___________ {week,
month, other} which is consistent with the Father’s current payroll cycle.

Upon the termination of the obligation of child support for one of the parties’
children, child support in the amount of $______ for the remaining_______ children
{total number of remaining children} shall be paid commencing _______________
{month, day, year} and terminating _______________________ {month, day, year}.
This child support shall be paid in the amount of $____________ per ________
{week, month, other} consistent with the Father’s current payroll cycle.

{Insert paragraph for the child support obligation, including the amount, and
commencement and termination dates, for the remaining minor or dependent
children, which shall be payable as the obligation for each child ceases.}

The Father shall pay child support until all minor or dependent children: reach the
age of 18; become emancipated, marry, join the armed services, die, or become self-

Florida Supreme Court Approved Family Law Form 12.970(e), Order Granting Petition for Temporary Custody by
Extended Family (03/15)
- 456 -
supporting; or until further order of the court or agreement of the parties. The child
support obligation shall continue beyond the age of 18 and until high school
graduation for any child who is dependent in fact, between the ages of 18 and 19,
and is still in high school, performing in good faith with a reasonable expectation of
graduation before the age of 19.

If the child support ordered deviates from the guidelines more than 5%, the factual
findings which support that deviation are: __________________________________
_____________________________________________________________________
____________________________________________________________________.

b) Mother’s Obligation
The Mother shall be obligated to pay child support at the rate of $____________ per
month for the ______ children {total number of parties’ minor or dependent
children} commencing _____________________ {month, day, year} and terminating
______________________ {month, day, year}. Child support shall be paid in the
amount of $_________ per _________ {week, month, other} consistent with the
Mother’s current payroll cycle.

Upon the termination of the obligation of child support for one of the parties’
children, child support in the amount of $___________ for the remaining ______
children {total number of remaining children} shall be paid commencing
_______________ {month, day, year} and terminating ________________________
{month, day, year}. This child support shall be paid in the amount of $____________
per _____________{week, month, other} consistent with the Mother’s current
payroll cycle.

{Insert paragraph for the child support obligation, including the amount, and
commencement and termination dates, for the remaining minor or dependent
children which shall be payable as the obligation for each child ceases.}

The Mother shall pay child support until all of the minor or dependent children:
reach the age of 18; become emancipated, marry, join the armed services, die, or
become self-supporting; or until further order of the court or agreement of the
parties. The child support obligation shall continue beyond the age of 18 and until
high school graduation for any child who is dependent in fact, between the ages of
18 and 19, and is still in high school, performing in good faith with a reasonable
expectation of graduation before the age of 19.

Florida Supreme Court Approved Family Law Form 12.970(e), Order Granting Petition for Temporary Custody by
Extended Family (03/15)
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4. Arrearages/Retroactive Child Support
a) The _____ Mother _____ Father owes child support arrearages in the amount of
$_____________ as of {date} ________________ to the other parent. The child
support arrearages shall be repaid in the amount of $_________ per month, payable
_____ in accordance with the employer’s payroll cycle, and in any event at least
once per month _____other {explain} ______________________________________
commencing {date} _____________________, until paid in full including statutory
interest.

b) The _____ Mother _____ Father owes retroactive child support in the amount of
$___________ as of {date} ________________ to the Petitioner. The retroactive
child support shall be repaid in the amount of $_______ per month, payable _____
in accordance with the employer’s payroll cycle, and in any event at least once per
month _____other {explain} ____________________________________________
_____________________________________________________________________
commencing {date} ______________________, until paid in full including statutory
interest.

5. Insurance
{Choose all that apply}
a) The _____ Mother _____ Father shall be required to maintain _____ health and/or
_____ dental insurance for the parties’ minor child(ren), so long as reasonable in
cost and accessible to the child(ren). The party providing insurance shall be required
to convey insurance cards demonstrating said coverage to the Petitioner and other
parent.
OR
_____ Health and/or _____ dental insurance is either not reasonable in cost or
accessible to the child(ren) at this time.

b) ____ Reasonable and necessary uninsured medical/dental/prescription drug costs
for the minor child(ren) shall be assessed as follows:
_____ Shared equally by both parents.
_____ Prorated according to the child support guidelines percentages.
_____ Other {explain} ______________________________________________

As to these uninsured medical/dental/prescription drug expenses, the party who
incurs the expense shall submit a request for reimbursement to the parent or
parents within 30 days, and the parent or parents, within 30 days of receipt, shall
submit the applicable reimbursement for that expense.

Florida Supreme Court Approved Family Law Form 12.970(e), Order Granting Petition for Temporary Custody by
Extended Family (03/15)
- 458 -
SECTION V. METHOD OF PAYMENT

The parent(s) shall pay court-ordered child support and arrearages, if any, as follows:
1. Place of Payment

a) ____Parent(s) shall pay court-ordered support directly to either the State
Disbursement Unit or the central depository, as required by statute, along with any
fee required by statute.

b) ____ The Petitioner and the Parent(s) have requested and the Court finds that it is in
the best interest of the child(ren) that support payments need not be directed
through either the State Disbursement Unit or the central depository at this time;
however, any party may subsequently apply, pursuant to section 61.13(1)(d)(3),
Florida Statutes, to require payment through either the State Disbursement Unit or
the central depository.

2. Income Deduction
(If applicable)
a) ____ Immediate. _____ Mother _____ Father, hereinafter, Obligor(s), shall pay
through income deduction, pursuant to a separate Income Deduction Order which
shall be effective immediately. Obligor is individually responsible for paying this
support obligation until all of said support is deducted from his/her income. Until
support payments are deducted, the Obligor is responsible for making timely
payments directly to the State Disbursement Unit or the Petitioner as previously set
forth in this Order.
b) ____ Deferred. Income deduction is ordered this day, but it shall not be effective
until a delinquency of $_____________, or, if not specified, an amount equal to one
month’s obligation occurs. Income deduction is not being implemented immediately
based on the following findings: Income deduction is not in the best interests of the
child(ren) because: {explain} _____________________________________________
_____________________________________________________________________
____________________________________________________________________.
AND
There is proof of timely payment of a previously ordered obligation without an
Income Deduction Order,
AND
_____ there is an agreement by the Obligor(s) to advise the Title IV-D agency, the
clerk of court, and the Petitioner of any change in Payor and/or health insurance OR
_____ there is a signed, written agreement providing an alternative arrangement
between the Petitioner and the Obligor(s) and, at the option of the IV-D agency, by

Florida Supreme Court Approved Family Law Form 12.970(e), Order Granting Petition for Temporary Custody by
Extended Family (03/15)
- 459 -
the IV-D agency in IV-D cases in which there is an assignment of support rights to the
state, reviewed and entered into the record by the court.

3. Bonus/one-time payments.
{Choose one only}

_____ All
_____ __________%
_____ No income paid in the form of a bonus or other similar one-time payment, up to
the amount of any arrearage or the remaining balance thereof owed pursuant to this
order, shall be forwarded to the Petitioner pursuant to the payment method prescribed
above.

4. Other provisions relating to method of payment: _______________________________
_______________________________________________________________________.

SECTION VI. ATTORNEY’S FEES, COSTS, AND SUIT MONEY
{Choose one only}
1. The ____ Petitioner’s _____Respondents’ request(s) for attorney’s fees, costs, and suit
money is (are) denied because ______________________________________________
_______________________________________________________________________.

2. ____ The Court finds there is a need for and ability to pay attorney’s fees, costs, and suit
money. _____ Petitioner _____ Respondent(s) is (are) ordered to pay the other party
$___________ in attorney’s fees, and $ ___________ in costs. The Court further finds
that the attorney’s fees are awarded based on the reasonable rate of
$________________ per hour and _________ reasonable hours. Other provisions
relating to attorney’s fees, costs, and suit money are as follows: ___________________
_______________________________________________________________________.

SECTION VII. OTHER PROVISIONS

1. Other Provisions ________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________.

2. The Court reserves jurisdiction to modify and enforce this Order for Temporary Custody.

Florida Supreme Court Approved Family Law Form 12.970(e), Order Granting Petition for Temporary Custody by
Extended Family (03/15)
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DONE AND ORDERED in ______________________, Florida on {date} __________________

_____________________________
CIRCUIT JUDGE

I certify that a copy of this Order for Temporary Custody was:
( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the parties and any
entities listed below on {date} _________________________.

by ________________________________
{Clerk of court or designee}.
Petitioner (or his or her attorney)
Respondents (or his or her attorney)
_____State Disbursement Unit
_____Central Depository
_____Other _________________________________

Florida Supreme Court Approved Family Law Form 12.970(e), Order Granting Petition for Temporary Custody by
Extended Family (03/15)
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IN THE CIRCUIT COURT OF THE _________________________ JUDICIAL CIRCUIT
IN AND FOR __________________________ COUNTY, FLORIDA

Case No: ______________________
Division: ______________________

__________________________________,
Petitioner,
and
__________________________________,
Respondent/Father

__________________________________,
Respondent/Mother.

ORDER GRANTING PETITION FOR
CONCURRENT CUSTODY BY EXTENDED FAMILY

This case came before this Court for a hearing on a Petition for Concurrent Custody by
Extended Family. The Court, having reviewed the file and heard the testimony, makes these
findings of fact and reaches these conclusions of law:

SECTION I. FINDINGS:

1. The Court has jurisdiction over the subject matter and the parties.

3. The Petitioner, {full legal name} _____________________________________ is the
{extended family relationship} _________________________________ of the child(ren).

4. The Petitioner currently has physical custody of the child(ren) and has had physical
custody of the child(ren) for at least 10 days in any 30-day period within the last 12
months.

Florida Supreme Court Approved Family Law Form 12.970(f), Order Granting Petition for Concurrent Custody by
Extended Family (03/15)
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5. The Petitioner does not have signed, written documentation from the parent(s) which is
sufficient to enable the custodian to do all the things necessary to care for the child(ren)
which are available to custodians who have an order for temporary custody by extended
family.

6. The Mother {full legal name} _________________________________ of the child(ren):
{choose one only}
____ Filed a Waiver and Consent
____ Was served with the petition and failed to file an Answer
____ Is deceased as evidenced by: _______________________________________

7. The Father {full legal name} _________________________________ of the child(ren):
{choose one only}
____ Filed a Waiver and Consent
____ Was served with the petition and failed to file an Answer
____ Is deceased as evidenced by: _______________________________________

8. It is in the best interest of the child(ren) for the Petitioner to have concurrent custody.

SECTION II: CONCURRENT CUSTODY

1. The Petitioner,___________________________________________________, is granted
concurrent custody of the minor child(ren).

2. The Petitioner shall have all the concurrent rights and responsibilities of a legal parent.

3. The Petitioner is authorized to make all reasonable and necessary decisions for the
minor child(ren), including but not limited to:
a) Consent to all necessary and reasonable medical and dental care for the
child(ren), including nonemergency surgery and psychiatric care;

b) Secure copies of the child(ren)’s records, held by third parties, that are necessary
for the care of the child(ren), including, but not limited to: medical, dental, and
psychiatric records; birth certificates and other records; and educational records,

c) Enroll the child(ren) in school and grant or withhold consent for the child(ren) to
be tested or placed in special school programs, including exceptional education;
and

d) Do all other things necessary for the care of the child(ren).

Florida Supreme Court Approved Family Law Form 12.970(f), Order Granting Petition for Concurrent Custody by
Extended Family (03/15)
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Florida Supreme Court Approved Family Law Form 12.970(f), Order Granting Petition for Concurrent Custody by
Extended Family (03/15)
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SECTION III. CHILD SUPPORT

1. The Petitioner ____ did ____ did not request the establishment of child support.

2. ____ If child support is requested, the parents have received personal or substituted
service of process, the petition requests an order for support of the child(ren), and there
is evidence of the parents’ ability to pay the support ordered. The _____ Mother
_____ Father has the present ability to pay child support.
{Choose one only}
a.____ The amounts in the Child Support Guidelines Worksheet, Florida Family Law
Rules of Procedure Form 12.902(e) filed by the ( ) Mother ( ) Father are correct;
OR
b.____ The Court makes the following findings:
The Mother’s net monthly income is $____________, (Child Support Guidelines ____%).
The Father’s net monthly income is $_____________, (Child Support Guidelines ____%)
Monthly child care costs are $_________________.
Monthly health/dental insurance costs are $_____________.
OR
c.____ The ( ) Mother ( ) Father is currently ordered to pay child support to the other
parent in the amount of $_____________ per ________________ as established in the
case of (style of case and number} _________________________________________
_____________________________________________________________________.
_____ All of the child support or _____ a portion of the child support in the amount of
$___________ shall be redirected to the Petitioner.

3. Amount
a) Father’s Obligation
The Father shall be obligated to pay child support at the rate of $__________ per month
for the _____children {total number of parties’ minor or dependent children}
commencing ____________ {month, day, year} and terminating _____________
{month, day, year}. Child support shall be paid in the amount of $______________ per
_____________ {week, month, other} which is consistent with the Father’s current
payroll cycle.

Upon the termination of child support for one of the parties’ children, child support in
the amount of $_____________ for the remaining _____ children {total number of
remaining children} shall be paid commencing __________________ {month, day, year}
and terminating _________________________ {month, day, year}. This child support
shall be paid in the amount of $___________ per ____________{week, month, other}
consistent with the Father’s current payroll cycle.

Florida Supreme Court Approved Family Law Form 12.970(f), Order Granting Petition for Concurrent Custody by
Extended Family (03/15)
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{Insert paragraph for the child support obligation, including the amount, and
commencement and termination dates, for the remaining minor or dependent
children, which shall be payable as the obligation for each child ceases.}

The Father shall pay child support until all of the minor or dependent children: reach the
age of 18, become emancipated, marry, join the armed services, die, or become self-
supporting; or until further order of the court or agreement of the parties. The child
support obligation shall continue beyond the age of 18 and until high school graduation
for any child who is dependent in fact, between the ages of 18 and 19, and is still in high
school, performing in good faith with a reasonable expectation of graduation before the
age of 19.

If the child support ordered deviates from the guidelines more than 5%, the factual
findings which support that deviation are: ____________________________________
_______________________________________________________________________
_______________________________________________________________________.

b) Mother’s Obligation
The Mother shall be obligated to pay child support at the rate of $____________ per
month for the _______children {total number of parties’ minor or dependent children}
commencing__________________________ {month, day, year} and terminating
__________________ {month, day, year}. Child support shall be paid in the amount of
$__________per ______________ {week, month, other} consistent with the Mother’s
current payroll cycle.

Upon the termination of the obligation of child support for one of the parties’ children,
child support in the amount of $__________ for the remaining ______ children {total
number of remaining children} shall be paid commencing _____________________
{month, day, year} and terminating ________________________ month, day, year}. This
child support shall be paid in the amount of $______________ per _______________
{week, month, other} consistent with the Mother’s current payroll cycle.

The Mother shall pay child support until all of the minor or dependent children: reach
the age of 18; become emancipated, marry, join the armed services, die, or become self-
supporting; or until further order of the court or agreement of the parties. The child
support obligation shall continue beyond the age of 18 and until high school graduation
for any child who is dependent in fact, between the ages of 18 and 19, and is still in high

Florida Supreme Court Approved Family Law Form 12.970(f), Order Granting Petition for Concurrent Custody by
Extended Family (03/15)
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school, performing in good faith with a reasonable expectation of graduation before the
age of 19.

If the child support ordered deviates from the guidelines more than 5%, the factual
findings which support that deviation are:______________________________________
________________________________________________________________________
_______________________________________________________________________.

4. Arrearages/Retroactive Child Support
c) The _____ Mother _____ Father owes child support arrearages in the amount of
$__________ as of {date} ________________ to the other parent. The child
support arrearages shall be repaid in the amount of $_______ per month,
payable _____ in accordance with the employer’s payroll cycle, and in any event
at least once per month _____other {explain} ____________________________

__________________________________________________________________
commencing {date} ______________________ , until paid in full including
statutory interest.

d) The _____ Mother _____ Father owes retroactive child support in the amount of
$___________ as of {date} ________________ to the Petitioner. The retroactive
child support shall be repaid in the amount of $_______ per month, payable
_____in accordance with the employer’s payroll cycle, and in any event at least
once per month _____ other {explain} _________________________________
__________________________________________________________________
commencing {date} ______________________, until paid in full including
statutory interest.

5. Insurance
{Choose all that apply}
c) The _____ Mother _____ Father shall be required to maintain _____ health
and/or _____ dental insurance for the parties’ minor child(ren), so long as
reasonable in cost and accessible to the child(ren). The party providing insurance
shall be required to convey insurance cards demonstrating said coverage to the
Petitioner and other parent.
OR
_____ Health and/or _____ dental insurance is either not reasonable in cost or
accessible to the child(ren) at this time.

d) _____ Reasonable and necessary uninsured medical/dental/prescription drug
costs for the minor child(ren) shall be assessed as follows:
_____ Shared equally by both parents.

Florida Supreme Court Approved Family Law Form 12.970(f), Order Granting Petition for Concurrent Custody by
Extended Family (03/15)
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_____ Prorated according to the child support guidelines percentages.
_____ Other {explain} ____________________________________________

SECTION IV. METHOD OF PAYMENT

The parent(s) shall pay court-ordered child support and arrearages, if any, as follows:
1. Place of Payment

a) _____Parents shall pay court-ordered support directly to either the State
Disbursement Unit or the central depository, as required by statute, along with any
applicable fee required by statute.

b) ____ The Petitioner and the Parents have requested and the court finds that it is in
the best interest of the child(ren) that support payments need not be directed
through either the State Disbursement Unit or the central depository at time;
however, any party may subsequently apply, pursuant to 61.13(1)(d)(3), Florida
Statutes, to require payment through either the State Disbursement Unit or the
central depository.

2. Income Deduction
(If applicable)
a) _____ Immediate. _____ Mother _____ Father, hereinafter, Obligor(s), shall pay
through income deduction, pursuant to a separate Income Deduction Order which
shall be effective immediately. Obligor is individually responsible for paying this
support obligation until all of said support is deducted from his/her income. Until
support payments are deducted, the Obligor is responsible for making timely
payments directly to the State Disbursement Unit or the Petitioner as previously set
forth in this Order.
b) _____ Deferred. Income deduction is ordered this day, but it shall not be effective
until a delinquency of $_____________, or, if not specified, an amount equal to one
month’s obligation occurs. Income deduction is not being implemented immediately
based on the following findings: Income deduction is not in the best interests of the
child(ren) because: {explain}
_____________________________________________________

Florida Supreme Court Approved Family Law Form 12.970(f), Order Granting Petition for Concurrent Custody by
Extended Family (03/15)
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_______________________________________________________________ .
AND
There is proof of timely payment of a previously ordered obligation without an
Income Deduction Order,
AND
_____ there is an agreement by the Obligor(s) to advise the Title IV-D agency, the
clerk of court, and the Petitioner of any change in Payor and/or health insurance OR
_____ there is a signed, written agreement providing an alternative arrangement
between the Petitioner and Obligor(s) and, at the option of the IV-D agency, by the
IV-D agency in IV-D cases in which there is an assignment of support rights to the
state, reviewed and entered into the record by the court.

3. Bonus/one-time payments.
{Choose one only}
_____ All
_____ __________%
_____ No income paid in the form of a bonus or other similar one-time payment, up to
the amount of any arrearage or the remaining balance thereof owed pursuant to this
order, shall be forwarded to the Petitioner pursuant to the payment method prescribed
above.

4. Other provisions relating to method of payment: _______________________________
________________________________________________________________________

SECTION V. ATTORNEY’S FEES, COSTS, AND SUIT MONEY
{Choose one only}

1. The _____ Petitioner’s _____ Respondents’ request(s) for attorney’s fees, costs, and suit
money is (are) denied because _____________________________________________
_____________________________________________________________________ .

2. _____ The Court finds there is a need for and ability to pay attorney’s fees, costs, and
suit money. _____ Petitioner _____ Respondent(s) is (are) ordered to pay the other
party $_____________ in attorney’s fees, and $ ___________ in costs. The Court
further finds that the attorney’s fees are awarded based on the reasonable rate of
$________________ per hour and ______ reasonable hours. Other provisions relating
to attorney’s fees, costs, and suit money are as follows: __________________________
_______________________________________________________________________.

SECTION VI. OTHER PROVISIONS

Florida Supreme Court Approved Family Law Form 12.970(f), Order Granting Petition for Concurrent Custody by
Extended Family (03/15)
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1. Other Provisions _________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

2. The Court reserves jurisdiction to modify and enforce this Order for Concurrent Custody.

3. The granting of concurrent custody does not affect the ability of the child(ren)’s parent
or parents to obtain physical custody of the child(ren) at any time.

DONE AND ORDERED in _____________________, Florida on {date} ____________________

_____________________________
CIRCUIT JUDGE

I certify that a copy of this Order for Concurrent Custody was: ( ) mailed ( ) faxed and
mailed ( ) e-mailed ( ) hand-delivered to the parties and any entities listed below on
{date}________________________.

by____________________________

{Clerk of court or designee}

Petitioner (or his or her attorney)
Respondents (or his or her attorney)
_____State Disbursement Unit
_____Central Depository
_____Other _________________________________

Florida Supreme Court Approved Family Law Form 12.970(f), Order Granting Petition for Concurrent Custody by
Extended Family (03/15)
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INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.980(a)
PETITION FOR INJUNCTION FOR PROTECTION AGAINST DOMESTIC
VIOLENCE (03/15)

When should this form be used?

If you are a victim of any act of domestic violence or have reasonable cause to believe that you are in
imminent danger of becoming a victim of domestic violence, you can use this form to ask the court for a
protective order prohibiting domestic violence. Because you are making a request to the court, you are
called the petitioner. The person whom you are asking the court to protect you from is called the
respondent. Domestic violence includes: assault, aggravated assault, battery, aggravated battery,
sexual assault, sexual battery, stalking, aggravated stalking, kidnapping, false imprisonment, or any
other criminal offense resulting in physical injury or death to petitioner by any of petitioner’s family or
household members. In determining whether you have reasonable cause to believe you are in
imminent danger of becoming a victim of domestic violence, the court must consider all relevant factors
alleged in the petition, including, but not limited to the following:
1. The history between the petitioner and the respondent, including threats, harassment, stalking,
and physical abuse.
2. Whether the respondent has attempted to harm the petitioner or family members or individuals
closely associated with the petitioner.
3. Whether the respondent has threatened to conceal, kidnap, or harm the petitioner’s child or
children.
4. Whether the respondent has intentionally injured or killed a family pet.
5. Whether the respondent has used, or has threatened to use, against the petitioner any weapons
such as guns or knives.
6. Whether the respondent has physically restrained the petitioner from leaving the home or
calling law enforcement.
7. Whether the respondent has a criminal history involving violence or the threat of violence.
8. The existence of a verifiable order of protection issued previously or from another jurisdiction.
9. Whether the respondent has destroyed personal property, including, but not limited to,
telephones or other communications equipment, clothing, or other items belonging to the
petitioner.
10. Whether the respondent engaged in any other behavior or conduct that leads the petitioner to
have reasonable cause to believe that he or she is in imminent danger of becoming a victim of
domestic violence.

Instructions for Florida Supreme Court Approved Family Law Form 12.980(a), Petition for Injunction for Protection
Against Domestic Violence (03/15)
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The domestic violence laws only apply to your situation if the respondent is your spouse, former spouse,
related to you by blood or marriage, living with you now or has lived with you in the past (if you are or
were living as a family), or the other parent of your child(ren) whether or not you have ever been
married or ever lived together. With the exception of persons who have a child in common, the family
or household members must be currently residing together or have in the past resided together in the
same single dwelling unit. If the respondent is not one of the above, you should look at Petition for
Injunction for Protection Against Repeat Violence, Florida Supreme Court Approved Family Law Form
12.980(f), to determine if your situation will qualify for an injunction for protection against repeat
violence, or Petition for Injunction for Protection Against Dating Violence, Florida Supreme Court
Approved Family Law Form 12.980(n), to determine if your situation will qualify for an injunction for
protection against dating violence, or Petition for Injunction for Protection Against Sexual Violence,
Florida Supreme Court Approved Family Law Form 12.980(q), to determine if your situation will qualify
for an injunction for protection against sexual violence.

If you are under the age of eighteen and you have never been married or had the disabilities of nonage
removed by a court, then one of your parents, custodians, or your legal guardian must sign this petition
with you.

This form should be typed or printed in black ink. You should complete this form (giving as much detail
as possible) and sign it in front of a notary public or the clerk of the circuit court in the county where
you live. The clerk will take your completed petition to a judge. You should keep a copy for your records.
If you have any questions or need assistance completing this form, the clerk or family law intake staff
will help you.

What should I do if the judge grants my petition?

If the facts contained in your petition convince the judge that you are a victim of domestic violence or
that an imminent danger of domestic violence exists, the judge will sign either an immediate
Temporary Injunction for Protection Against Domestic Violence with Minor Child(ren), Florida
Supreme Court Approved Family Law Form 12.980(c)(1) or an immediate Temporary Injunction for
Protection Against Domestic Violence without Minor Child(ren), Florida Supreme Court Approved
Family Law Form 12.980(c)(2). A temporary injunction is issued without notice to the respondent. The
clerk will give your petition, the temporary injunction, and any other papers filed with your petition to
the sheriff or other law enforcement officer for personal service on the respondent. The temporary
injunction will take effect immediately after the respondent is served with a copy of it. It lasts until a full
hearing can be held or for a period of 15 days, whichever comes first. The court may extend the
temporary injunction beyond 15 days for a good reason, which may include failure to obtain service on
the respondent.

Instructions for Florida Supreme Court Approved Family Law Form 12.980(a), Petition for Injunction for Protection
Against Domestic Violence (03/15)
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The temporary injunction is issued ex parte. This means that the judge has considered only the
information presented by one side-- YOU. The temporary injunction gives a date that you must appear
in court for a hearing. At that hearing, you will be expected to testify about the facts in your petition.
The respondent will be given the opportunity to testify at this hearing, also. At the hearing, the judge
will decide whether to issue either a Final Judgment of Injunction for Protection Against Domestic
Violence with Minor Child(ren)(After Notice), Florida Supreme Court Approved Family Law Form
12.980(d)(1), or a Final Judgment of Injunction for Protection Against Domestic Violence without
Minor Child(ren)(After Notice), Florida Supreme Court Approved Family Law Form 12.980(d)(2). Either
of these final judgments will remain in effect for a specific time period or until modified or dissolved by
the court. If either you or the respondent do not appear at the final hearing, the temporary injunction
may be continued in force, extended, or dismissed, and/or additional orders may be granted,
including entry of a permanent injunction and the imposition of court costs. You and respondent will
be bound by the terms of any injunction issued at the final hearing.

IF EITHER YOU OR RESPONDENT DO NOT APPEAR AT THE FINAL HEARING, YOU WILL BOTH BE BOUND
BY THE TERMS OF ANY INJUNCTION ISSUED IN THIS MATTER.

If the judge signs a temporary or final injunction, the clerk will provide you with the necessary copies.
Make sure that you keep one certified copy of the injunction with you at all times!

What can I do if the judge denies my petition?

If your petition is denied solely on the grounds that it appears to the court that no imminent danger of
domestic violence exists, the court will set a full hearing, at the earliest possible time, on your petition,
unless you request that no hearing be set. The respondent will be notified by personal service of your
petition and the hearing. If your petition is denied, you may: amend your petition by filing a
Supplemental Affidavit in Support of Petition for Injunction for Protection Against Domestic Violence,
Repeat or Dating Violence, Florida Family Law Form 12.980 (g); attend the hearing and present facts
that support your petition; and/or dismiss your petition.
Where can I look for more information?

Before proceeding, you should read General Information for Self-Represented Litigants found at the
beginning of these forms. The words that are in bold underline are defined in that section. The clerk of
the circuit court or family law intake staff will help you complete any necessary domestic violence forms
and can give you information about local domestic violence victim assistance programs, shelters, and
other related services. You may also call the Domestic Violence Hotline at 1-800-500-1119. For further
information, see Chapter 741, Florida Statutes, and Rule 12.610, Florida Family Law Rules of Procedure.

IMPORTANT INFORMATION REGARDING E-FILING

Instructions for Florida Supreme Court Approved Family Law Form 12.980(a), Petition for Injunction for Protection
Against Domestic Violence (03/15)
- 473 -
The Florida Rules of Judicial Administration now require that all petitions, pleadings, and documents be
filed electronically except in certain circumstances. Self-represented litigants may file petitions or other
pleadings or documents electronically; however, they are not required to do so. If you choose to file
your pleadings or other documents electronically, you must do so in accordance with Florida Rule of
Judicial Administration 2.525, and you must follow the procedures of the judicial circuit in which you file.
The rules and procedures should be carefully read and followed.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Special notes...

With this form you may also need to file the following:
 Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida
Supreme Court Approved Family Law Form 12.902(d), must be completed and filed if you
are asking the court to determine issues with regard to your parenting plan or time-sharing
for a minor child(ren).
 Parenting plan means a document created to govern the relationship between the
parents relating to the decisions that must be made regarding the minor child(ren) and must
contain a time-sharing schedule for the parents and child(ren). The issues concerning the
minor child(ren) may include, but are not limited to, the child(ren)’s education, health care,
and physical, social, and emotional well-being. In creating the plan, all circumstances
between the parents, including their historic relationship, domestic violence, and other

Instructions for Florida Supreme Court Approved Family Law Form 12.980(a), Petition for Injunction for Protection
Against Domestic Violence (03/15)
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factors must be taken into consideration. The Parenting Plan shall be developed and agreed
to by the parents and approved by a court, or, established by the court, with or without the
use of a court-ordered parenting plan recommendation. If the parents cannot agree, or if
the parents agreed to a plan that is not approved by the court, a Parenting Plan shall
established by the court. “Time-sharing schedule” means a timetable that must be included
in the Parenting Plan that specifies the time, including overnights and holidays, that a minor
child will spend with each parent. If developed and agreed to by the parents of a minor
child, it must be approved by the court. If the parents cannot agree, of if their agreed-upon
schedule is not approved by the court, the schedule shall be established by the court.
 Notice of Social Security Number, Florida Supreme Court Approved Family Law Form
12.902(j), must be completed and filed if you are asking the court to determine issues of
temporary child support.
 Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or
(c), must be completed and filed if you are seeking temporary alimony or temporary child
support.
 Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form
12.902(e), MUST be filed with the court at or prior to a hearing to establish or modify child
support.

Additionally, if you fear that disclosing your address to the respondent would put you in danger, you
should complete a Request for Confidential Filing of Address, Florida Supreme Court Approved Family
Law Form 12.980(h), and file it with the clerk of the circuit court and write confidential in the space
provided on the petition.

Instructions for Florida Supreme Court Approved Family Law Form 12.980(a), Petition for Injunction for Protection
Against Domestic Violence (03/15)
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IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
,
Petitioner,
and

,
Respondent.

PETITION FOR INJUNCTION FOR PROTECTION
AGAINST DOMESTIC VIOLENCE

I, {full legal name} , being sworn, certify that the
following statements are true:

SECTION I. PETITIONER
(This section is about you. It must be completed. However, if you fear that disclosing your address to
the respondent would put you in danger, you should complete and file a Request for Confidential Filing
of Address, Florida Supreme Court Approved Family Law Form 12.980(h), and write confidential in the
space provided on this form for your address and telephone number.)

1. Petitioner’s current address is: {street address}
{city, state and zip code}
Telephone Number: {area code and number}
Physical description of Petitioner:
Race: _____ Sex: Male _____ Female _____ Date of Birth: _________________________

2. Petitioner’s attorney’s name, address, and telephone number is:
.
(If you do not have an attorney, write none.)

SECTION II. RESPONDENT
(This section is about the person you want to be protected from. It must be completed.)

1. Respondent’s current address is: {street address, city, state, and zip code}
.
Respondent’s Driver’s License number is: {if known} .

Florida Supreme Court Approved Family Law Form 12.980(a), Petition for Injunction for Protection Against
Domestic Violence (03/15)
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2. Respondent is: {Indicate all that apply}

a. _____ the spouse of Petitioner. Date of Marriage:
b. _____ the former spouse of Petitioner.
Date of Marriage:
Date of Dissolution of Marriage:
c. _____ related by blood or marriage to Petitioner.
Specify relationship:
d. _____ a person who is or was living in one home with Petitioner, as if a family.
e._____ a person with whom Petitioner has a child in common, even if Petitioner and Respondent
never were married or living together.

3. Petitioner has known Respondent since {date} .

4. Respondent’s last known place of employment:
Employment address:
Working hours:

5. Physical description of Respondent:
Race: _____ Sex: Male _____ Female _____Date of Birth: _______________________________
Height: Weight: Eye Color: Hair Color:
Distinguishing marks or scars:
Vehicle: (make/model) Color: Tag Number:

6. Other names Respondent goes by (aliases or nicknames):

7. Respondent’s attorney’s name, address, and telephone number is:

(If you do not know whether Respondent has an attorney, write unknown. If Respondent does not have
an attorney, write none.)

SECTION III. CASE HISTORY AND REASON FOR SEEKING PETITION (This section must be completed.)

1. Has Petitioner ever received or tried to get an injunction for protection against domestic
violence against Respondent in this or any other court?
_ Yes _ No If yes, what happened in that case? {Include case number, if known}

Florida Supreme Court Approved Family Law Form 12.980(a), Petition for Injunction for Protection Against
Domestic Violence (03/15)
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2. Has Respondent ever received or tried to get an injunction for protection against domestic
violence against Petitioner in this or any other court?
_ Yes _ No If yes, what happened in that case? {Include case number, if known}

3. Describe any other court case that is either going on now or that happened in the past,
including a dissolution of marriage, paternity action, or child support enforcement action,
between Petitioner and Respondent {Include city, state, and case number, if known}:
______________________________________________________________________________.

4. Petitioner is either a victim of domestic violence or has reasonable cause to believe he or she is
in imminent danger of becoming a victim of domestic violence because respondent has: {mark
all sections that apply and describe in the spaces below the incidents of violence or threats of
violence, specifying when and where they occurred, including, but not limited to, locations such
as a home, school, place of employment, or time-sharing exchange}

a. _____committed or threatened to commit domestic violence defined in section 741.28,
Florida Statutes, as any assault, aggravated assault, battery, aggravated battery, sexual
assault, sexual battery, stalking, aggravated stalking, kidnapping, false imprisonment, or any
criminal offense resulting in physical injury or death of one family or household member by
another. With the exception of persons who are parents of a child in common, the family or
household members must be currently residing or have in the past resided together in the
same single dwelling unit.
b. _____previously threatened, harassed, stalked, or physically abused the petitioner.
c. _____attempted to harm the petitioner or family members or individuals closely associated
with the petitioner.
d. _____threatened to conceal, kidnap, or harm the petitioner's child or children.
e. _____intentionally injured or killed a family pet.
f. _____used, or has threatened to use, against the petitioner any weapons such as guns or
knives.
g. _____physically restrained the petitioner from leaving the home or calling law enforcement.
h. _____a criminal history involving violence or the threat of violence (if known).
i. _____another order of protection issued against him or her previously or from another
jurisdiction (if known).
j. _____destroyed personal property, including, but not limited to, telephones or other
communication equipment, clothing, or other items belonging to the petitioner.
k. _____engaged in any other behavior or conduct that leads the petitioner to have reasonable
cause to believe he or she is in imminent danger of becoming a victim of domestic violence.

Florida Supreme Court Approved Family Law Form 12.980(a), Petition for Injunction for Protection Against
Domestic Violence (03/15)
- 478 -
Below is a brief description of the latest act of violence or threat of violence that causes Petitioner to
honestly fear imminent domestic violence by Respondent.
(Use additional sheets if necessary.)

On {date} ________, at {location} ___________________________________,
Respondent:

.
_______ Please indicate here if you are attaching additional pages to continue these facts.

5. Additional Information
{Indicate all that apply}
a.____Other acts or threats of domestic violence as described on attached sheet.
b.____This or other acts of domestic violence have been previously reported to {person or
agency}:_____________________________________________________________
c.____ Respondent owns, has, and/or is known to have guns or other weapons.
Describe weapon(s):
d. ____ Respondent has a drug problem.
e.____ Respondent has an alcohol problem.
f. ____ Respondent has a history of mental health problems. If checked, answer the following,
if known:
Has Respondent ever been the subject of a Baker Act proceeding? _____ Yes _____ No
Is Respondent supposed to take medication for mental health problems?

Florida Supreme Court Approved Family Law Form 12.980(a), Petition for Injunction for Protection Against
Domestic Violence (03/15)
- 479 -
_____Yes _____ No
If yes, is Respondent currently taking his/her medication? _____ Yes _____ No

SECTION IV. TEMPORARY EXCLUSIVE USE AND POSSESSION OF HOME (Complete this section only if
you want the Court to grant you temporary exclusive use and possession of the home that you share
with the Respondent.)

1. Petitioner claims the following about the home that Petitioner and Respondent share or that
Petitioner left because of domestic violence:
{Indicate all that apply}
a.____ Petitioner needs the exclusive use and possession of the home that the parties share at {street
address} ,
{city, state, zip code} .

b.____Petitioner cannot get another safe place to live because:

c. ____If kept out of the home, Respondent has the money to get other housing or may live without
money at {street address} ,
{city, state, zip code} .

2. The home is:
{Choose one only}
a.____ owned or rented by Petitioner and Respondent jointly.

b.____ solely owned or rented by Petitioner.

c.____ solely owned or rented by Respondent.

SECTION V. TEMPORARY PARENTING PLAN WITH TEMPORARY TIME-SHARING SCHEDULE FOR MINOR
CHILD(REN) (Complete this section only if you are asking the court to provide a temporary parenting
plan, including a temporary time-sharing schedule with regard to, the minor child or children of the
parties which might involve prohibiting or limiting time-sharing or requiring that it be supervised by a
third party. You must be the natural parent, adoptive parent, or guardian by court order of the minor
child(ren). If you are asking the court to provide a temporary parenting plan, including a temporary
time-sharing schedule with regard to, the minor child or children of the parties which might involve
prohibiting or limiting time-sharing or requiring that it be supervised by a third party, you must also

Florida Supreme Court Approved Family Law Form 12.980(a), Petition for Injunction for Protection Against
Domestic Violence (03/15)
- 480 -
complete and file a Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida
Supreme Court Approved Family Law Form 12.902(d).)

Note: If the paternity of the minor child(ren) listed below has not been established through either
marriage or court order, the Court may deny a request to provide a temporary parenting plan,
including a temporary time-sharing schedule with regard to, the minor child or children, and/or a
request for child support.

1. Petitioner is the natural parent, adoptive parent, or guardian by court order of the minor
child(ren) whose name(s) and age(s) is (are) listed below.
Name Birth date

2. The minor child(ren) for whom Petitioner is asking the court to provide a temporary parenting
plan, including a temporary time-sharing schedule with regard to:
{Choose one only}
a.____saw the domestic violence described in this petition happen.

b.____were at the place where the domestic violence happened but did not see it.

c.____were not there when the domestic violence happened this time but have seen
previous acts of domestic violence by Respondent.

d.____have not witnessed domestic violence by Respondent.

3. Name any other minor child(ren) who were there when the domestic violence happened.
Include child(ren)’s name, age, and parents’ names.

4. Temporary Parenting Plan and Temporary Time-Sharing Schedule
{Indicate all that apply}
a.____ Petitioner requests that the Court provide a temporary parenting plan, including a temporary
time-sharing schedule with regard to, the minor child or children of the parties, as follows:
___________________________________________________________________________

Florida Supreme Court Approved Family Law Form 12.980(a), Petition for Injunction for Protection Against
Domestic Violence (03/15)
- 481 -
__________________________________________________________________________ _
___________________________________________________________________________ .

b.____ Petitioner requests that the Court order supervised exchange of the minor child(ren) or exchange
through a responsible person designated by the Court. The following person is suggested as a
responsible person for purposes of such exchange. {Explain}:
________________________________________________________________________ .

c.____ Petitioner requests that the Court limit time-sharing by Respondent with the minor child(ren).
{Explain}:

d.____ Petitioner requests that the Court prohibit time-sharing by Respondent with the minor child(ren)
because Petitioner genuinely fears that Respondent imminently will abuse, remove, or hide the minor
child(ren) from Petitioner. {Explain}:

e.____Petitioner requests that the Court allow only supervised time-sharing by Respondent with the
minor child(ren). Explain: _____________________________________________________
______________________________________________________________________________
______________________________________________________________________________.

Supervision should be provided by a Family Visitation Center, or other
(specify):_______________________________________________________________________

SECTION VI. TEMPORARY SUPPORT (Complete this section only if you are seeking financial support
from the Respondent. You must also complete and file a Family Law Financial Affidavit, Florida Family
Law Rules of Procedure Form 12.902(b) or (c), and Notice of Social Security Number, Florida Supreme
Court Approved Family Law Form 12.902(j), if you are seeking child support. A Child Support Guidelines
Worksheet, Florida Family Law Rules of Procedure Form 12.902(e), must be filed with the court at or
prior to a hearing to establish or modify child support.) {Indicate all that apply}
1. ____Petitioner claims a need for the money he or she is asking the Court to make
Respondent pay, and that Respondent has the ability to pay that money.

2. ____Petitioner requests that the Court order Respondent to pay the following
temporary alimony to Petitioner. (Petitioner must be married to Respondent to ask for
temporary alimony.) Temporary Alimony Requested $__________ every: _____ week
_____ other week _____ month.

Florida Supreme Court Approved Family Law Form 12.980(a), Petition for Injunction for Protection Against
Domestic Violence (03/15)
- 482 -
3. _____Petitioner requests that the Court order Respondent to pay the following
temporary child support to Petitioner. (The Respondent must be the natural parent,
adoptive parent, or guardian by court order of the minor child(ren) for the court to
order the Respondent to pay child support.) Temporary child support is requested in
the amount of $______________ every: _____ week _____ other week _____
month.

SECTION VII. INJUNCTION (This section summarizes what you are asking the Court to include in the
injunction. This section must be completed.)

1. Petitioner asks the Court to enter a TEMPORARY INJUNCTION for protection against domestic
violence that will be in place from now until the scheduled hearing in this matter.

2. Petitioner asks the Court to enter, after a hearing has been held on this petition, a final
judgment on injunction prohibiting Respondent from committing any acts of domestic violence
against Petitioner and:

a. prohibiting Respondent from going to or within 500 feet of any place the Petitioner lives;

b. prohibiting Respondent from going to or within 500 feet of the Petitioner’s place(s) of employment or
school; the address of Petitioner’s place(s) of employment or school is:
_____________________________________________________________________________________
_______________________________________________________________________.

c. prohibiting Respondent from contacting Petitioner by mail, by telephone, through another person, or
in any other manner;

d. prohibiting Respondent from knowingly and intentionally going to or within 100 feet of Petitioner’s
motor vehicle.

e. prohibiting Respondent from defacing or destroying Petitioner’s personal property.

{Indicate all that apply}
f. _____prohibiting Respondent from going to or within 500 feet of the following place(s) Petitioner or
Petitioner’s minor child(ren) must go often {include address}: _________________

g.____ granting Petitioner temporary exclusive use and possession of the home Petitioner and

Florida Supreme Court Approved Family Law Form 12.980(a), Petition for Injunction for Protection Against
Domestic Violence (03/15)
- 483 -
Respondent share;

h.____ granting Petitioner on a temporary basis 100% of the time sharing with the parties’ minor
child(ren);

i.____establishing a temporary parenting plan including a temporary time-sharing schedule for the
parties’ minor child(ren);

j.____granting temporary alimony for Petitioner;

k.____granting temporary child support for the minor child(ren);

l.____ordering Respondent to participate in treatment, intervention, and/or counseling services;

m.____referring Petitioner to a certified domestic violence center; and any other terms the Court deems
necessary for the protection of Petitioner and/or Petitioner’s child(ren), including injunctions or
directives to law enforcement agencies, as provided in Section 741.30, Florida Statutes.

I UNDERSTAND THAT BY FILING THIS PETITION, I AM ASKING THE COURT TO HOLD A HEARING ON
THIS PETITION, THAT BOTH RESPONDENT AND I WILL BE NOTIFIED OF THE HEARING, AND THAT I
MUST APPEAR AT THE HEARING. I UNDERSTAND THAT IF EITHER RESPONDENT OR I FAIL TO APPEAR
AT THE HEARING, WE WILL BE BOUND BY THE TERMS OF ANY INJUNCTION ISSUED AT THAT HEARING.

I HAVE READ EVERY STATEMENT MADE IN THIS PETITION, AND EACH STATEMENT IS TRUE AND
CORRECT. I UNDERSTAND THAT THE STATEMENTS MADE IN THIS PETITION ARE BEING MADE UNDER
PENALTY OF PERJURY, PUNISHABLE AS PROVIDED IN SECTION 837.02, FLORIDA STATUTES.

____________(initials)
Dated:

_______________________________

Signature of Petitioner
STATE OF FLORIDA
COUNTY OF _________________________

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

Florida Supreme Court Approved Family Law Form 12.980(a), Petition for Injunction for Protection Against
Domestic Violence (03/15)
- 484 -
{Print, type, or stamp commissioned name of notary or clerk.}
_ Personally known
_ Produced identification
Type of identification produced ________________________________

Florida Supreme Court Approved Family Law Form 12.980(a), Petition for Injunction for Protection Against
Domestic Violence (03/15)
- 485 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.: _____________________
Division: ____________________
__________________,
Petitioner,
and

__________________,
Respondent.

ORDER SETTING HEARING ON PETITION FOR INJUNCTION
FOR PROTECTION AGAINST
( ) DOMESTIC VIOLENCE ( ) REPEAT VIOLENCE
( ) DATING VIOLENCE ( ) SEXUAL VIOLENCE ( ) STALKING
WITHOUT ISSUANCE OF AN INTERIM TEMPORARY INJUNCTION

A Petition for Injunction for Protection Against: Domestic Violence filed under section 741.30, Florida
Statutes; Repeat, Dating, or Sexual Violence filed under section 784.046, Florida Statutes; or Stalking
filed under section 784.0485, Florida Statutes, has been reviewed. This Court has jurisdiction of the
parties and of the subject matter. Upon review of the Petition, this Court concludes that a Temporary
Injunction for Protection Against Domestic Violence; Repeat, Dating, or Sexual Violence; or Stalking,
pending the hearing scheduled below, NOT be entered at this time but that an injunction may be
entered after the hearing, depending on the findings made by the Court at that time.

FINDINGS

The Court finds that based upon the facts, as stated in the Petition alone and without a hearing on the
matter, there is no appearance of an immediate and present danger of domestic violence; repeat,
dating, or sexual violence; or stalking, or that stalking exists. Therefore, there is not a sufficient factual
basis upon which the court can enter a Temporary Injunction for Protection Against Domestic, Repeat,
Dating, or Sexual Violence, or Stalking, prior to a hearing. A hearing is scheduled on the Petition for
Injunction for Protection Against Domestic, Repeat, Dating, or Sexual Violence, or Stalking, in Section II
of this Order. Petitioner may amend or supplement the Petition at any time to state further reasons
why a Temporary Injunction should be ordered which would be in effect until the hearing scheduled
below.

Florida Supreme Court Approved Family Law Form 12.980(b)(1), Order Setting Hearing on Petition for Injunction
for Protection Against Domestic Violence, Repeat Violence, Dating Violence, Sexual Violence, or Stalking, without
Issuance of an Interim Temporary Injunction (03/15)
- 486 -
NOTICE OF HEARING
Petitioner and Respondent are ordered to appear and testify at a hearing on the Petition for Injunction
for Protection Against Domestic, Repeat, Dating, or Sexual Violence, or Stalking on: {date} ,
at _ a.m./p.m. at {location}_________________________________________ at which time the Court
will consider whether a Final Judgment of Injunction for Protection Against Domestic, Repeat, Dating, or
Sexual Violence, or Stalking should be entered. If entered, the injunction will remain in effect until a
fixed date set by the Court or until modified or dissolved by the Court. At the hearing, the Court will
determine whether other things should be ordered, including, for example, such matters as time-sharing
and support.

If Petitioner and/or Respondent do not appear, orders may be entered, including entry of a permanent
injunction and the imposition of court costs. Petitioner and Respondent will be bound by the terms of
any injunction or order issued at the final hearing.

IF EITHER PETITIONER OR RESPONDENT DO NOT APPEAR AT THE FINAL HEARING, HE OR SHE WILL BE
BOUND BY THE TERMS OF ANY INJUNCTION OR ORDER ISSUED IN THIS MATTER.

All witnesses and evidence, if any, must be presented at this time. In cases where temporary support
issues have been alleged in the pleadings, each party is ordered to bring his or her financial affidavit
(Florida Family Law Rules of Procedure Form 12.902(b) or (c)), tax return, pay stubs, and other evidence
of financial income to the hearing.

NOTICE: Because this is a civil case, there is no requirement that these proceedings be transcribed at
public expense.

YOU ARE ADVISED THAT IN THIS COURT:

a. ____ a court reporter is provided by the court.

b. ____ electronic recording only is provided by the court. A party may arrange in advance for
the services of and provide for a court reporter to prepare a written transcript of
the proceedings at that party’s expense.

c. ____ in repeat, dating, and sexual violence cases, no electronic recording or court reporting
services are provided by the court. A party may arrange in advance for the services of
and provide for a court reporter to prepare a written transcript of the proceedings at
that party’s expense.

A RECORD, WHICH INCLUDES A TRANSCRIPT, MAY BE REQUIRED TO SUPPORT AN APPEAL. THE PARTY
SEEKING THE APPEAL IS RESPONSIBLE FOR HAVING THE TRANSCRIPT PREPARED BY A COURT REPORTER.
THE TRANSCRIPT MUST BE FILED WITH THE REVIEWING COURT OR THE APPEAL MAY BE DENIED

Nothing in this order limits Petitioner’s rights to dismiss the petition.

DONE AND ORDERED in _______________________, Florida, on _______________________.

CIRCUIT JUDGE

COPIES TO:
Petitioner: _____ by hand delivery in open Court
_____ U.S. mail

Respondent: _____ forwarded to sheriff for service

Other: __

I CERTIFY the foregoing is a true copy of the original Order Setting Hearing on Petition for Injunction as
it appears on file in the office of the Clerk of the Circuit Court of __________________________ County,
Florida, and that I have furnished copies of this order as indicated above.

CLERK OF THE CIRCUIT COURT
(SEAL)
By:

Case No.:
Division:
__________________,
Petitioner,

and

___________________,
Respondent.

ORDER DENYING PETITION FOR INJUNCTION FOR PROTECTION AGAINST
( ) DOMESTIC VIOLENCE ( ) REPEAT VIOLENCE
( ) DATING VIOLENCE ( ) SEXUAL VIOLENCE ( ) STALKING
The Court has reviewed the Petition for Injunction for Protection Against Domestic, Repeat, Dating, or
Sexual Violence, or Stalking filed in this cause, and finds that Petitioner has failed to comply with one or
more statutory requirements applicable to that petition, including the following:

1. _____ Petitioner has failed to allege in a petition for domestic violence that Respondent is a family
or household member as that term is defined by Chapter 741, Florida Statutes.
2. _____ Petitioner has used a petition form other than that which is approved by the Court and the
form used lacks the statutorily required components.
3. _____ Petitioner has failed to complete a mandatory portion of the petition.
4. _____ Petitioner has failed to sign the petition.
5. _____ Petitioner has failed to allege facts sufficient to support the entry of an injunction for
protection against domestic, repeat, dating, or sexual violence; or stalking because:

.
6. _____Other:

It is therefore, ORDERED AND ADJUDGED that the petition is denied without prejudice to amend or
supplement the petition to cure the above stated defects.

Florida Supreme Court Approved Family Law Form 12.980(b)(2), Order Denying Petition for Injunction for
Protection Against Domestic Violence, Repeat Violence, Dating Violence, or Sexual Violence, or Stalking (03/15)
- 490 -
DONE AND ORDERED in___________________________, Florida, on ____________.

CIRCUIT JUDGE

COPIES TO:
Petitioner:
_______ by hand delivery in open Court
_______ by U.S.mail
_____by e-mail to designated e-mail address(es)

I CERTIFY the foregoing is a true copy of the original Order Denying Hearing on Petition for Injunction as
it appears on file in the office of the Clerk of the Circuit Court of ____________________ County,
Florida, and that I have furnished copies of this order as indicated above.

CLERK OF THE CIRCUIT COURT
(SEAL)
By:
{Deputy Clerk or Judicial Assistant}

Florida Supreme Court Approved Family Law Form 12.980(b)(2), Order Denying Petition for Injunction for
Protection Against Domestic Violence, Repeat Violence, Dating Violence, or Sexual Violence, or Stalking (03/15)
- 491 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
,
Petitioner,

and

,
Respondent.

TEMPORARY INJUNCTION FOR PROTECTION AGAINST
DOMESTIC VIOLENCE WITH MINOR CHILD(REN)
The Petition for Injunction for Protection Against Domestic Violence under section 741.30, Florida
Statutes, and other papers filed in this Court have been reviewed. Under the laws of Florida, the Court
has jurisdiction of the Petitioner and the subject matter and has jurisdiction of the Respondent upon
service of the temporary injunction.

It is intended that this protection order meet the requirements of 18 U.S.C. Section 2265 and
therefore intended that it be accorded full faith and credit by the court of another state or Indian tribe
and enforced as if it were the order of the enforcing state or of the Indian tribe.

SECTION I. NOTICE OF HEARING

Because this Temporary Injunction for Protection Against Domestic Violence has been issued without
prior notice to Respondent, the Petitioner and Respondent are instructed that they are scheduled to
appear and testify at a hearing regarding this matter on {date} ____________________________, at
____ a.m./p.m., when the Court will consider whether to issue a Final Judgment of Injunction for
Protection Against Domestic Violence, which would remain in effect until modified or dissolved by the
Court, and whether other things should be ordered, including, for example, such matters as time-sharing
and support. The hearing will be before The Honorable {name}_________________________________,
at {room name/number, location, address, city}
_____________________________________________________________________________, Florida.

If Petitioner and/or Respondent do not appear, this temporary injunction may be continued in force,
extended, dismissed, and/or additional orders may be granted, including entry of a permanent
injunction and the imposition of court costs. Petitioner and Respondent will be bound by the terms of
any injunction or order issued at the final hearing.

IF EITHER PETITIONER OR RESPONDENT DO NOT APPEAR AT THE FINAL HEARING, HE OR SHE WILL BE
BOUND BY THE TERMS OF ANY INJUNCTION OR ORDER ISSUED IN THIS MATTER.

Florida Supreme Court Approved Family Law Form 12.980(c)(1), Temporary Injunction for Protection Against
Domestic Violence with Minor Child(ren) (03/15)
- 492 -
All witnesses and evidence, if any, must be presented at this time. In cases where temporary support
issues have been alleged in the pleadings, each party is ordered to bring his or her financial affidavit
Florida Family Law Rules of Procedure Form 12.902(b) or (c)), tax return, pay stubs, and other evidence
of financial income to the hearing.

NOTICE: Because this is a civil case, there is no requirement that these proceedings be transcribed at
public expense.

YOU ARE ADVISED THAT IN THIS COURT:

a. ____a court reporter is provided by the court.

b. ____an electronic recording only is provided by the court. A party may arrange in advance
for the services of and provide for a court reporter to prepare a written transcript of the
proceedings at that party’s expense.

{identify applicable court personnel by name, address, and phone number} at
least 7 days before your scheduled court appearance, or immediately upon
receiving this notification if the time before the scheduled appearance is less
than 7 days; if you are hearing impaired, call 711.

SECTION II. FINDINGS

The statements made under oath by Petitioner make it appear that section 741.30, Florida Statutes,
applies to the parties. It also appears that Petitioner is a victim of domestic violence by Respondent,
and/or Petitioner has reasonable cause to believe he/she is in imminent danger of becoming a victim of
domestic violence by Respondent, and that there is an immediate and present danger of domestic
violence to Petitioner or persons lawfully with Petitioner.

SECTION III. TEMPORARY INJUNCTION AND TERMS

This injunction shall be effective until the hearing set above and in no event for longer than 15 days,
unless extended by court order. If a final order of injunction is issued, the terms of this temporary
injunction will be extended until service of the final injunction is effected upon Respondent. This
injunction is valid and enforceable in all counties of the State of Florida. The terms of this injunction
may not be changed by either party alone or by both parties together. Only the Court may modify the

Florida Supreme Court Approved Family Law Form 12.980(c)(1), Temporary Injunction for Protection Against
Domestic Violence with Minor Child(ren) (03/15)
- 493 -
terms of this injunction. Either party may ask the Court to change or end this injunction.

Any violation of this injunction, whether or not at the invitation of Petitioner or anyone else, may
subject Respondent to civil or indirect criminal contempt proceedings, including the imposition of a
fine or imprisonment. Certain willful violations of the terms of this injunction, such as: refusing to
vacate the dwelling that the parties share; going to or being within 500 feet of Petitioner's residence,
going to Petitioner’s place of employment, school, or other place prohibited in this injunction;
telephoning, contacting or communicating with Petitioner if prohibited by this injunction; knowingly
or intentionally coming within 100 feet of Petitioner’s motor vehicle, whether or not it is occupied;
defacing or destroying Petitioner’s personal property; refusing to surrender firearms or ammunition if
ordered to do so by the court; or committing an act of domestic violence against Petitioner
constitutes a misdemeanor of the first degree punishable by up to one year in jail, as provided by
sections 775.082 and 775.083, Florida Statutes. In addition, it is a federal criminal felony offense,
punishable by up to life imprisonment, depending on the nature of the violation, to cross state lines or
enter Indian country for the purpose of engaging in conduct that is prohibited in this injunction. 18
U.S.C. Section 2262.

ORDERED and ADJUDGED:

1. Violence Prohibited. Respondent shall not commit, or cause any other person to commit, any
acts of domestic violence against Petitioner. Domestic violence includes: assault, aggravated
assault, battery, aggravated battery, sexual assault, sexual battery, stalking, aggravated stalking,
kidnapping, false imprisonment, or any other criminal offense resulting in physical injury or
death to Petitioner or any of Petitioner's family or household members. Respondent shall not
commit any other violation of the injunction through an intentional unlawful threat, word or act
to do violence to the Petitioner.

2. No Contact. Respondent shall have no contact with Petitioner unless otherwise provided in
this Section, or unless paragraph 14 below provides for contact connected with the temporary
parenting plan and temporary time-sharing with respect to the minor child(ren).

a. Unless otherwise provided herein, Respondent shall have no contact with Petitioner. Respondent
shall not directly or indirectly contact Petitioner in person, by mail, e-mail, fax, telephone, through
another person, or in any other manner. Further, Respondent shall not contact or have any third party
contact anyone connected with Petitioner's employment or school to inquire about Petitioner or to send
any messages to Petitioner. Unless otherwise provided herein, Respondent shall not go to, in, or within
500 feet of: Petitioner’s current residence {list address}

or any residence to which Petitioner may move; Petitioner’s current or any subsequent place of
employment {list address of current employment} __________________________
or place where Petitioner attends school {list address of school}
;
or the following other places (if requested by Petitioner) where Petitioner or Petitioner’s minor
child(ren) go often: .

Respondent may not knowingly come within 100 feet of Petitioner's automobile at any time.

Florida Supreme Court Approved Family Law Form 12.980(c)(1), Temporary Injunction for Protection Against
Domestic Violence with Minor Child(ren) (03/15)
- 494 -
b. _____Other provisions regarding contact:

3. Firearms.
{Initial all that apply; write N/A if does not apply}

a. _____Respondent shall not use or possess a firearm or ammunition.

b. _____Respondent shall surrender any firearms and ammunition in the Respondent's
possession to the County Sheriff's Department until further order of the
court.

c. _____Other directives relating to firearms and ammunition:
_________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________ .

NOTE: RESPONDENT IS ADVISED THAT, IF A PERMANENT INJUNCTION FOR PROTECTION AGAINST
DOMESTIC VIOLENCE IS ISSUED FOLLOWING A HEARING REGARDING THIS MATTER, IN MOST CASES IT
WILL BE A VIOLATION OF SECTION 790.233, FLORIDA STATUTES, AND A FIRST DEGREE MISDEMEANOR,
FOR RESPONDENT TO HAVE IN HIS OR HER CARE, CUSTODY, POSSESSION OR CONTROL ANY FIREARM
OR AMMUNITION. ADDITIONALLY, IT WILL BE A FEDERAL CRIMINAL FELONY OFFENSE TO SHIP OR
TRANSPORT IN INTERSTATE OR FOREIGN COMMERCE, OR POSSESS IN OR AFFECTING COMMERCE,
ANY FIREARM OR AMMUNITION; OR TO RECEIVE ANY FIREARM OR AMMUNITION WHICH HAS BEEN
SHIPPED OR TRANSPORTED IN INTERSTATE OR FOREIGN COMMERCE WHILE SUBJECT TO SUCH AN
INJUNCTION. 18 U.S.C. SECTION 922(g)(8).

4. Mailing Address or Designated E-Mail Address(es). Respondent shall notify the Clerk of the
Court of any change in either his or her mailing address, or designated e-mail address(es), within
10 days of the change. All further papers (excluding the final injunction, if entered without
Respondent being present at the hearing, and pleadings requiring personal service) shall be
served either by mail to Respondent’s last known mailing address or by e-mail to Respondent’s
designated e-mail address(es). Service shall be complete upon mailing or e-mailing.

5. Additional order(s) necessary to protect Petitioner from domestic violence:

Florida Supreme Court Approved Family Law Form 12.980(c)(1), Temporary Injunction for Protection Against
Domestic Violence with Minor Child(ren) (03/15)
- 495 -
TEMPORARY EXCLUSIVE USE AND POSSESSION OF HOME

{Initial all that apply; write N/A if does not apply}
6. ____Possession of the Home. ____ Petitioner ____ Respondent shall have temporary exclusive
use and possession of the dwelling located at: ______________________________________
.

7. ____Transfer of Possession of the Home. A law enforcement officer with jurisdiction over the
home shall accompany ____ Petitioner ____ Respondent to the home, and shall place ____
Petitioner ____ Respondent in possession of the home.

8. ____Personal Items. ____ Petitioner ____ Respondent, in the presence of a law enforcement
officer, may return to the premises described above ____ on {date} _____,
at ______a.m./p.m., or ____ at a time arranged with the law enforcement department with
jurisdiction over the home, for the purpose of obtaining his or her clothing and items of
personal health and hygiene and tools of the trade. A law enforcement officer with jurisdiction
over the home from which these items are to be retrieved shall accompany ____ Petitioner
____ Respondent to the home and stand by to insure that he/she vacates the premises with only his/her
personal clothing, toiletries, tools of the trade, and any items listed in paragraph 10 below. The law
enforcement agency shall not be responsible for storing or transporting any property. IF THE
RESPONDENT IS NOT AWARDED POSSESSION OF THE HOME AND GOES TO THE HOME WITHOUT A
LAW ENFORCEMENT OFFICER, IT IS A VIOLATION OF THIS INJUNCTION.

9. ____ Petitioner ____ Respondent shall not damage or remove any furnishings or fixtures from
the parties' former shared premises.

10. ____Other:_____________________________________________________________________

TEMPORARY SUPPORT

Temporary support, if requested by Petitioner in the Petition for Injunction for Protection Against
Domestic Violence, will be addressed by the Court after notice to Respondent and hearing on the
matter.

TEMPORARY PARENTING PLAN WITH TIME-SHARING WITH MINOR CHILD(REN)

Florida Supreme Court Approved Family Law Form 12.980(c)(1), Temporary Injunction for Protection Against
Domestic Violence with Minor Child(ren) (03/15)
- 496 -
11. Jurisdiction. {Initial one only}
______ Jurisdiction to determine issues relating to parenting plan and time-sharing with respect
to any minor child(ren) listed in paragraph 12 below is proper under the Uniform Child Custody
Jurisdiction and Enforcement Act (UCCJEA).
______ Jurisdiction is exclusive to the dependency court, and accordingly no order is made
herein. (Case Number ____________________________.)

12. Temporary Order for 100% Time-Sharing With Respect to Minor Child(ren). ____ Petitioner
____ Respondent shall, on a temporary basis, have 100% time sharing with respect to the
parties’ minor child(ren) listed below:

Name Birth date

When requested by the parent to whom 100% time-sharing is awarded on a temporary basis herein, law
enforcement officers shall use any and all reasonable and necessary force to physically deliver the minor
child(ren) listed above to the parent to whom 100% time-sharing is awarded on a temporary basis
herein. The other parent shall not take the child(ren) from the parent to whom 100% time-sharing is
awarded on a temporary basis herein or any child care provider or other person entrusted by the parent
to whom 100% time-sharing is awarded on a temporary basis herein with the care of the child(ren).

{Initial if applies; write N/A if does not apply}
______ Neither party shall remove the minor child(ren) from the State of Florida, which is the
jurisdiction of this Court, prior to the hearing on this temporary injunction. Violation of this custody
order may constitute a felony of the third degree under sections 787.03 and 787.04, Florida Statutes.

13. Contact with Minor Child(ren). Unless otherwise provided in paragraph 14 below, the
____ Petitioner ____ Respondent (i.e., the parent to whom 100% time-sharing is not awarded on a
temporary basis herein) shall have no contact with the parties’ minor child(ren) until further order of
the Court.

14. Other Additional Provisions Relating to the Minor Child(ren).

Florida Supreme Court Approved Family Law Form 12.980(c)(1), Temporary Injunction for Protection Against
Domestic Violence with Minor Child(ren) (03/15)
- 497 -
SECTION IV. OTHER SPECIAL PROVISIONS
{This section to be used for inclusion of local provisions approved by the chief judge as provided in Florida
Family Law Rule 12.610.}
_________________________________________________________________________________
_________________________________________________________________________________
_______________________________________________________________________________

SECTION V. DIRECTIONS TO LAW ENFORCEMENT OFFICER IN ENFORCING THIS INJUNCTION
{Unless ordered otherwise by the judge, all provisions in this injunction are considered mandatory
provisions and should be interpreted as part of this injunction.}

1. The Sheriff of _____ County, or any other authorized law enforcement officer,
is ordered to serve this temporary injunction upon Respondent as soon as possible after its
issuance.

2. This injunction is valid in all counties of the State of Florida. Violation of this injunction should
be reported to the appropriate law enforcement agency. Law enforcement officers of the
jurisdiction in which a violation of this injunction occurs shall enforce the provisions of this
injunction and are authorized to arrest without warrant pursuant to section 901.15, Florida
Statutes, for any violation of its provisions which constitutes a criminal act under section 741.31,
Florida Statutes.

3. THIS INJUNCTION IS ENFORCEABLE IN ALL COUNTIES OF FLORIDA AND LAW ENFORCEMENT
OFFICERS MAY EFFECT ARRESTS PURSUANT TO SECTION 901.15(6), FLORIDA STATUTES. The
arresting agent shall notify the State Attorney's Office immediately after arrest.

4. THIS IS A “CUSTODY ORDER” FOR PURPOSES OF THE UCCJEA AND ALL STATUTES MAKING IT A
CRIME TO INTERFERE WITH CUSTODY UNDER CHAPTER 787 OF FLORIDA STATUTES AND
OTHER SIMILAR STATUTES.

5. Reporting alleged violations. If Respondent violates the terms of this injunction and there has
not been an arrest, Petitioner may contact the Clerk of the Circuit Court of the county in which
the violation occurred and complete an affidavit in support of the violation, or Petitioner may
contact the State Attorney’s office for assistance in filing an action for indirect civil contempt or
indirect criminal contempt. Upon receiving such a report, the State Attorney is hereby
appointed to prosecute such violations by indirect criminal contempt proceedings, or the State
Attorney may decide to file a criminal charge, if warranted by the evidence.

DONE AND ORDERED at ___________________________, Florida on .

CIRCUIT JUDGE

Florida Supreme Court Approved Family Law Form 12.980(c)(1), Temporary Injunction for Protection Against
Domestic Violence with Minor Child(ren) (03/15)
- 498 -
COPIES TO:

Sheriff of ___________________ County

Petitioner: (or his or her attorney)
_____ by U.S. Mail
_____ by hand-delivery in open court
_____by e-mail to designated e-mail address(es)

Respondent:
_____ forwarded to the Sheriff for service

_____ State’s Attorney’s Office
_____ Other:_________________________________

I CERTIFY the foregoing is a true copy of the original Temporary Injunction for Protection Against
Domestic Violence with Minor Child(ren) as it appears on file in the office of the Clerk of the Circuit
Court of __________________ County, Florida, and that I have furnished copies of this order as
indicated above.

CLERK OF THE CIRCUIT COURT
(SEAL)
By:
{Deputy Clerk or Judicial Assistant}

Florida Supreme Court Approved Family Law Form 12.980(c)(1), Temporary Injunction for Protection Against
Domestic Violence with Minor Child(ren) (03/15)
- 499 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR _____________ COUNTY, FLORIDA

Case No.:
Division:
_________________,
Petitioner,
and

_________________,
Respondent.

TEMPORARY INJUNCTION FOR PROTECTION AGAINST DOMESTIC
VIOLENCE WITHOUT MINOR CHILD(REN)
The Petition for Injunction for Protection Against Domestic Violence under section 741.30, Florida
Statutes, and other papers filed in this Court have been reviewed. Under the laws of Florida, the Court
has jurisdiction of the Petitioner and the subject matter and has jurisdiction of the Respondent upon
service of the temporary injunction.

SECTION I. NOTICE OF HEARING

Because this Temporary Injunction for Protection Against Domestic Violence has been issued without
prior notice to Respondent, the Petitioner and Respondent are instructed that they are scheduled to
appear and testify at a hearing regarding this matter on {date} _____________________ ,
at a.m./p.m., when the Court will consider whether to issue a Final Judgment of Injunction
for Protection Against Domestic Violence, which would remain in effect until modified or dissolved by
the Court, and whether other things should be ordered, including, for example, such matters as support.
The hearing will be before The Honorable {name} ,
at {room name/number, location, address, city}
______________________________________________________________________________, Florida.
If Petitioner and/or Respondent do not appear, this temporary injunction may be continued in force,
extended, dismissed, and/or additional orders may be granted, including entry of a permanent
injunction and the imposition of court costs. Petitioner and Respondent will be bound by the terms of
any injunction or order issued at the final hearing.

IF EITHER PETITIONER OR RESPONDENT DO NOT APPEAR AT THE FINAL HEARING, HE OR SHE WILL BE
BOUND BY THE TERMS OF ANY INJUNCTION OR ORDER ISSUED IN THIS MATTER.

Florida Supreme Court Approved Family Law Form 12.980(c)(2), Temporary Injunction for Protection Against
Domestic Violence without Minor Child(ren) (03/15)
- 500 -
All witnesses and evidence, if any, must be presented at this time. In cases where temporary support
issues have been alleged in the pleadings, each party is ordered to bring his or her financial affidavit
(Florida Family Law Rules of Procedure Form 12.902(b) or (c)), tax return, pay stubs, and other evidence
of financial income to the hearing.

NOTICE: Because this is a civil case, there is no requirement that these proceedings be transcribed at
public expense.

YOU ARE ADVISED THAT IN THIS COURT:

a. ____ a court reporter is provided by the court.

b. ____ an electronic recording only is provided by the court. A party may arrange in advance for the
services of and provide for a court reporter to prepare a written transcript of the proceedings at that
party’s expense.

{identify applicable court personnel by name, address and telephone number} at
least 7 days before your scheduled court appearance, or immediately upon
receiving this notification if the time before the scheduled appearance is less
than 7 days; if you are hearing impaired, call 711.

SECTION II. FINDINGS

SECTION III. TEMPORARY INJUNCTION AND TERMS

Florida Supreme Court Approved Family Law Form 12.980(c)(2), Temporary Injunction for Protection Against
Domestic Violence without Minor Child(ren) (03/15)
- 501 -
This injunction shall be effective until the hearing set above and in no event for longer than 15 days,
unless extended by court order. If a final order of injunction is issued, the terms of this temporary
injunction will be extended until service of the final injunction is effected upon Respondent. This
injunction is valid and enforceable in all counties of the State of Florida. The terms of this injunction
may not be changed by either party alone or by both parties together. Only the Court may modify the
terms of this injunction. Either party may ask the Court to change or end this injunction.

ORDERED and ADJUDGED:

1. Violence Prohibited. Respondent shall not commit, or cause any other person to commit, any
acts of domestic violence against Petitioner. Domestic violence includes: assault, aggravated assault,
battery, aggravated battery, sexual assault, sexual battery, stalking, aggravated stalking, kidnapping,
false imprisonment, or any other criminal offense resulting in physical injury or death to Petitioner or
any of Petitioner's family or household members. Respondent shall not commit any other violation of
the injunction through an intentional unlawful threat, word or act to do violence to the Petitioner.

2. No Contact. Respondent shall have no contact with Petitioner unless otherwise provided in
this section.
a. Unless otherwise provided herein, Respondent shall have no contact with Petitioner. Respondent
shall not directly or indirectly contact Petitioner in person, by mail, e-mail, fax, telephone, through
another person, or in any other manner. Further, Respondent shall not contact or have any third party
contact anyone connected with Petitioner's employment or school to inquire about Petitioner or to send
any messages to Petitioner. Unless otherwise provided herein, Respondent shall not go to, in, or within
500 feet of: Petitioner’s current residence {list address}

Florida Supreme Court Approved Family Law Form 12.980(c)(2), Temporary Injunction for Protection Against
Domestic Violence without Minor Child(ren) (03/15)
- 502 -
or the following other places (if requested by Petitioner) where Petitioner or Petitioner’s minor
child(ren) go often:

.
Respondent may not knowingly come within 100 feet of Petitioner's automobile at any time.
b. Other provisions regarding contact:
______________________________________________________________________________

3. Firearms.
{Initial all that apply; write N/A if does not apply}
a. _____Respondent shall not use or possess a firearm or ammunition.

b. _____Respondent shall surrender any firearms and ammunition in the Respondent's possession to
the _________ County Sheriff's Department until further order of the court.

c. _____Other directives relating to firearms and ammunition:

NOTE: RESPONDENT IS ADVISED THAT, IF A PERMANENT INJUNCTION FOR PROTECTION AGAINST
DOMESTIC VIOLENCE IS ISSUED FOLLOWING A HEARING REGARDING THIS MATTER, IN MOST CASES IT
WILL BE A VIOLATION OF SECTION 790.233, FLORIDA STATUTES, AND A FIRST DEGREE
MISDEMEANOR, FOR RESPONDENT TO HAVE IN HIS OR HER CARE, CUSTODY, POSSESSION OR
CONTROL ANY FIREARM OR AMMUNITION. ADDITIONALLY, IT WILL BE A FEDERAL CRIMINAL FELONY
OFFENSE TO SHIP OR TRANSPORT IN INTERSTATE OR FOREIGN COMMERCE, OR POSSESS IN OR
AFFECTING COMMERCE, ANY FIREARM OR AMMUNITION; OR TO RECEIVE ANY FIREARM OR
AMMUNITION WHICH HAS BEEN SHIPPED OR TRANSPORTED IN INTERSTATE OR FOREIGN COMMERCE
WHILE SUBJECT TO SUCH AN INJUNCTION. 18 U.S.C. SECTION 922(g)(8).

4. Mailing Address or Designated E-Mail Address(es). Respondent shall notify the Clerk of the
Court of any change in either his or her mailing address, or designated e-mail address(es), within 10 days
of the change. All further papers (excluding the final injunction, if entered without Respondent being
present at the hearing, and pleadings requiring personal service) shall be served either by mail to
Respondent’s last known mailing address or by e-mail to Respondent’s designated e-mail address(es).
Service shall be complete upon mailing or e-mailing.

5. Additional order(s) necessary to protect Petitioner from domestic violence:

Florida Supreme Court Approved Family Law Form 12.980(c)(2), Temporary Injunction for Protection Against
Domestic Violence without Minor Child(ren) (03/15)
- 503 -
.
TEMPORARY EXCLUSIVE USE AND POSSESSION OF HOME

{Initial all that apply; write N/A if does not apply}
6. ____Possession of the Home. ____ Petitioner ____ Respondent shall have temporary exclusive use and possession of
.

7. ____ Transfer of Possession of the Home. A law enforcement officer with jurisdiction over
the home shall accompany ____ Petitioner____ Respondent to the home, and shall place
____Petitioner ____ Respondent in possession of the home.

8. ____Personal Items. ____ Petitioner ____ Respondent, in the presence of a law
enforcement officer, may return to the premises described above ____ on ________________, at
_______,a.m./p.m., or ____ at a time arranged with the law enforcement department with jurisdiction
over the home, for the purpose of obtaining his or her clothing and items of personal health and hygiene
and tools of the trade. A law enforcement officer with jurisdiction over the home from which these
items are to be retrieved shall accompany ____ Petitioner
____ Respondent to the home and stand by to insure that he/she vacates the premises with
only his/her personal clothing, toiletries, tools of the trade, and any items listed in paragraph 10 below.
The law enforcement agency shall not be responsible for storing or transporting any property. IF THE
RESPONDENT IS NOT AWARDED POSSESSION OF THE HOME AND GOES TO THE HOME WITHOUT A
LAW ENFORCEMENT OFFICER, IT IS A VIOLATION OF THIS INJUNCTION.

9. ____ Petitioner ____ Respondent shall not damage or remove any furnishings or fixtures
from the parties' former shared premises.

10.____ Other: ___________________________________________________________

TEMPORARY SUPPORT

SECTION IV. OTHER SPECIAL PROVISIONS
{This section to be used for inclusion of local provisions approved by the chief judge as provided in Florida
Family Law Rule 12.610.}
___________________________________________________________________________
___________________________________________________________________________

Florida Supreme Court Approved Family Law Form 12.980(c)(2), Temporary Injunction for Protection Against
Domestic Violence without Minor Child(ren) (03/15)
- 504 -
___________________________________________________________________________ .

1. The Sheriff of _____ County, or any other authorized law enforcement officer,
is ordered to serve this temporary injunction upon Respondent as soon as possible after its issuance.

2. This injunction is valid in all counties of the State of Florida. Violation of this injunction should
be reported to the appropriate law enforcement agency. Law enforcement officers of the jurisdiction in
which a violation of this injunction occurs shall enforce the provisions of this injunction and are
authorized to arrest without warrant pursuant to section 901.15, Florida Statutes, for any violation of its
provisions which constitutes a criminal act under section 741.31, Florida Statutes.

3. THIS INJUNCTION IS ENFORCEABLE IN ALL COUNTIES OF FLORIDA AND LAW ENFORCEMENT
OFFICERS MAY EFFECT ARRESTS PURSUANT TO SECTION 901.15(6), FLORIDA STATUTES. The arresting
agent shall notify the State Attorney's Office immediately after arrest.

4. Reporting alleged violations. If Respondent violates the terms of this injunction and there has
not been an arrest, Petitioner may contact the Clerk of the Circuit Court of the county in which the
violation occurred and complete an affidavit in support of the violation, or Petitioner may contact the
State Attorney’s office for assistance in filing an action for indirect civil contempt or indirect criminal
contempt. Upon receiving such a report, the State Attorney is hereby appointed to prosecute such
violations by indirect criminal contempt proceedings, or the State Attorney may decide to file a criminal
charge, if warranted by the evidence.

DONE AND ORDERED in__________________________, Florida on ____________ .

CIRCUIT JUDGE

Florida Supreme Court Approved Family Law Form 12.980(c)(2), Temporary Injunction for Protection Against
Domestic Violence without Minor Child(ren) (03/15)
- 505 -
COPIES TO:

Sheriff of __________________ County

Petitioner: (or his or her attorney)
_____by U.S. Mail
_____ by hand-delivery in open court
_____by e-mail to designated e-mail address(es)

Respondent:
_____ forwarded to the sheriff for service

_____ State’s Attorney’s Office

_____ other:________________________

I CERTIFY the foregoing is a true copy of the original Temporary Injunction for Protection Against
Domestic Violence without Minor Child(ren) as it appears on file in the office of the Clerk of the Circuit
Court of _________________ County, Florida, and that I have furnished copies of this order as indicated
above.

CLERK OF THE CIRCUIT COURT
(SEAL)
By:
{Deputy Clerk or Judicial Assistant}

Florida Supreme Court Approved Family Law Form 12.980(c)(2), Temporary Injunction for Protection Against
Domestic Violence without Minor Child(ren) (03/15)
- 506 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
,
Petitioner,
and

,
Respondent.

FINAL JUDGMENT OF INJUNCTION FOR PROTECTION AGAINST DOMESTIC
VIOLENCE WITH MINOR CHILD(REN) (AFTER NOTICE)

The Petition for Injunction for Protection Against Domestic Violence under section 741.30, Florida
Statutes, and other papers filed in this Court have been reviewed. The Court has jurisdiction of the
parties and the subject matter.

SECTION I. HEARING

This cause came before the Court for a hearing to determine whether an Injunction for Protection
Against Domestic Violence in this case should be:
_____ issued ____ modified ____ extended.
The hearing was attended by:
____ Petitioner
____ Respondent
____ Petitioner’s Counsel
____ Respondent’s Counsel

SECTION II. FINDINGS

On {date} , a notice of this hearing was served on Respondent together
with a copy of Petitioner’s petition to this Court and the temporary injunction, if issued. Service was
within the time required by Florida law, and Respondent was afforded an opportunity to be heard.
After hearing the testimony of each party present and of any witnesses, or upon consent of
Respondent, the Court finds, based on the specific facts of this case, that Petitioner is a victim of
domestic violence or has reasonable cause to believe that he/she is in imminent danger of becoming a

This injunction shall be in full force and effect until either further order of the Court or
{date} . This injunction is valid and enforceable in all counties of the State of
Florida. The terms of this injunction may not be changed by either party alone or by both parties
together. Only the Court may modify the terms of this injunction. Either party may ask the Court to
change or end this injunction at any time.

ORDERED and ADJUDGED:

2. No Contact. Respondent shall have no contact with the Petitioner unless otherwise provided
in this section, or unless paragraphs 13 through 19 below provide for contact connected with
the temporary parenting plan and temporary time-sharing with respect to the minor
child(ren).
a. Unless otherwise provided herein, Respondent shall have no contact with Petitioner. Respondent
shall not directly or indirectly contact Petitioner in person, by mail, e-mail, fax, telephone, through
another person, or in any other manner. Further, Respondent shall not contact or have any third party
contact anyone connected with Petitioner's employment or school to inquire about Petitioner or to send
any messages to Petitioner. Unless otherwise provided herein, Respondent shall not go to, in, or within
500 feet of: Petitioner’s current residence {list address}

Florida Supreme Court Approved Family Law Form 12.980(d)(1), Final Judgment of Injunction for Protection
Against Domestic Violence with Minor Child(ren) (After Notice) (03/15)
- 508 -
___________________________________________________________________________
or any residence to which Petitioner may move; Petitioner’s current or any subsequent place of
employment {list address of current employment} ___________________________
______________________________________or place where Petitioner attends school {list address of
school} ;
or the following other places (if requested by Petitioner) where Petitioner or Petitioner’s minor
child(ren) go often:______________________________________________________

___________________________________________________________________________
Respondent may not knowingly come within 100 feet of Petitioner's automobile at any time.

b._____Other provisions regarding contact:

3. Firearms. Unless paragraph a. is initialed below, Respondent shall not have in his or her care,
custody, possession or control any firearm or ammunition. It is a violation of section 790.233,
Florida Statutes, and a first degree misdemeanor, for the respondent to have in his or her
care, custody, possession or control any firearm or ammunition.
[Initial if applies; write N/A if not applicable]
a.____Respondent is a state or local officer as defined in section 943.10(14), Florida Statutes, who holds
an active certification, who receives or possesses a firearm or ammunition for use in performing official
duties on behalf of the officer’s employing agency and is not prohibited by the court from having in his
or her care, custody, possession or control a firearm or ammunition. The officer’s employing agency
may prohibit the officer from having in his or her care, custody, possession or control a firearm or
ammunition.

b.____Respondent shall surrender any firearms and ammunition in the Respondent's possession to the
County Sheriff's Department.

c.____Other directives relating to firearms and ammunition:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________ .

NOTE: RESPONDENT IS ADVISED THAT IT IS A FEDERAL CRIMINAL FELONY OFFENSE TO SHIP OR
TRANSPORT IN INTERSTATE OR FOREIGN COMMERCE, OR POSSESS IN OR AFFECTING COMMERCE,
ANY FIREARM OR AMMUNITION; OR TO RECEIVE ANY FIREARM OR AMMUNITION WHICH HAS BEEN
SHIPPED OR TRANSPORTED IN INTERSTATE OR FOREIGN COMMERCE WHILE SUBJECT TO SUCH AN
INJUNCTION. 18 U.S.C. SECTION 922(g)(8).

4. Evaluation/Counseling.
[Initial all that apply; write N/A if does not apply]
a. The Court finds that Respondent has:

ii. ____been convicted of, had adjudication withheld on, or pled nolo contendere to a crime
involving violence or a threat of violence; and/or

iii. ____in this state or any other state, had at any time a prior injunction for protection against the
Respondent after a hearing with notice.

Note: If Respondent meets any of the above enumerated criteria, the Court must order the Respondent
to attend a batterers' intervention program unless it makes written factual findings stating why such a
program would not be appropriate. See Section 741.30(6)(e), Florida Statutes.

a. Within ____10 days ______ days, (but no more than 10 days) of the date of this injunction,
Respondent shall enroll in and thereafter without delay complete the following, and
Respondent shall provide proof of such enrollment to the Clerk of Circuit Court within
____ 30 days or ____ days, (but no more than 30 days) of the date of this injunction:

i. ___A certified batterers’ intervention program from a list of programs to be provided by
the Court or any entity designated by the Court. Respondent shall also successfully
complete any substance abuse or mental health evaluation that the assessing program
counselor deems necessary as a predicate to completion of the batterers’ intervention
program.

ii. ____A substance abuse evaluation at:_________________________________________
or a similarly qualified facility and any substance abuse treatment recommended by that
evaluation.

iii. ____A mental health evaluation by a licensed mental health professional at:
________________________________or any other similarly qualified facility and any
mental health treatment recommended by that evaluation.

iv. ____Other:______________________________________________________________
_______________________________________________________________________.

b. ____Although Respondent meets the statutory mandate of attendance at a batterers’
intervention program, the Court makes the following written findings as to why the
condition of batterers’ intervention program would be inappropriate: __________________

c. ____Petitioner is referred to a certified domestic violence center and is provided with a list
of certified domestic violence centers in this circuit, which Petitioner may contact.

Florida Supreme Court Approved Family Law Form 12.980(d)(1), Final Judgment of Injunction for Protection
Against Domestic Violence with Minor Child(ren) (After Notice) (03/15)
- 510 -
5. Mailing Address or Designated E-Mail Address(es). Respondent shall notify the Clerk of the
Court of any change in either his or her mailing address, or designated e-mail address(es), within 10 days
of the change. All further papers (excluding pleadings requiring personal service) shall be served either
by mail to Respondent’s last known mailing address or by e-mail to Respondent’s designated e-mail
address(es). Service shall be complete upon mailing or e-mailing.

6. Other provisions necessary to protect Petitioner from domestic violence: _________________

TEMPORARY EXCLUSIVE USE AND POSSESSION OF HOME
[Initial if applies; write N/A if not applicable]
7. ____Possession of the Home. ____ Petitioner ____ Respondent shall have temporary exclusive
use and possession of the dwelling located at:

8. ____Transfer of Possession of the Home. A law enforcement officer with jurisdiction over the
home shall accompany ____ Petitioner ____ Respondent to the home, and shall place
____ Petitioner ____ Respondent in possession of the home.

9. ____Personal Items. ____ Petitioner ____ Respondent, in the presence of a law enforcement
officer, may return to the premises described above on {date} ___, at
a.m./p.m., or ____ at a time arranged with the law enforcement department with
jurisdiction over the home, accompanied by a law enforcement officer only, for the purpose of
obtaining his or her clothing and items of personal health and hygiene and tools of the trade. A law
enforcement officer with jurisdiction over the premises shall go with
____ Petitioner ____ Respondent to the home and stand by to insure that he/she vacates the
premises with only his/her personal clothing, toiletries, tools of the trade, and any items listed in
paragraph 10 below. The law enforcement agency shall not be responsible for storing or transporting
any property. IF THE RESPONDENT IS NOT AWARDED POSSESSION OF THE HOME AND GOES TO THE
HOME WITHOUT A LAW ENFORCEMENT OFFICER, IT IS A VIOLATION OF THIS INJUNCTION.

10. ____The following other personal possessions may also be removed from the premises at this
time: ____________________________________________________________________
_______________________________________________________________________ .

11. ____Other: ___________________________________________________________________

12. Jurisdiction.
[Initial one only]
_____ Jurisdiction to determine issues relating to parenting plan and time-sharing with respect to any
minor child(ren) listed in paragraph 13 below is proper under the Uniform Child Custody Jurisdiction and
Enforcement Act (UCCJEA).

_____ Jurisdiction is exclusive to the dependency court, and accordingly no order is made herein. {Case
Number ____________________________.}

13. Temporary Parenting Plan for Minor Child(ren). Except for that time-sharing (if any) specified
for the other parent in paragraph 14, below, _____ Petitioner _____ Respondent shall on a
temporary basis have 100% of the time-sharing with the parties’ minor child(ren) listed below
and shall have sole decision-making responsibility until further court order:

Name Birth date

When requested by the parent to whom the majority of overnight time-sharing with the child(ren) is
awarded on a temporary basis herein, in this case the _____ Petitioner
_____ Respondent, law enforcement officers shall use any and all reasonable and necessary force to
physically deliver the minor child(ren) listed above to the parent to whom the majority of overnight
time-sharing with the child(ren) is awarded on a temporary basis herein. The other parent shall not take
the child(ren) from the parent to whom the majority of overnight time-sharing with the child(ren) is
awarded on a temporary basis herein or any child care provider or other person entrusted by the parent
to whom the majority of overnight time-sharing with the child(ren) is awarded on a temporary basis
herein with the care of the child(ren).

14. Temporary Parenting Plan with Time-Sharing for Minor Child(ren). The Petitioner and
Respondent shall have time-sharing with the minor child(ren) on the following schedule:
{Initial one only}
a. ____ Petitioner ____ Respondent shall have 100% of time-sharing and ____ Petitioner
____ Respondent shall have 0% of time sharing with the child(ren) until further order of the Court.
Until further order of the Court, all parenting decisions shall be made by the parent with 100% of the
time-sharing.

Florida Supreme Court Approved Family Law Form 12.980(d)(1), Final Judgment of Injunction for Protection
Against Domestic Violence with Minor Child(ren) (After Notice) (03/15)
- 512 -
b. ____ Petitioner ____ Respondent shall have time-sharing from ___________ a.m./p.m. to
______a.m./p.m. on the following day(s)_________________________________. The other parent will
have the remaining time-sharing. ____________________________
_______________________________________________________________________
_______________________________________________________________________ .
c. ____Other:__________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________ .

15. Limitations on Time-Sharing. The time-sharing specified in paragraph 14, above, for
____ Petitioner ____ Respondent with the child(ren) shall be:
[Initial all that apply; write N/A if does not apply]
a.______ unsupervised

b.______ supervised by the following specified responsible adult:_______________________

c.______ at a supervised visitation center located at:
_____________________________________________________________________________
,
and shall be subject to the available times and rules of the supervised visitation center. The cost
associated with the services of the supervised visitation center shall be paid by the: {choose one}
_____ parent to whom the majority of overnight time-sharing with the child(ren) is awarded on a
temporary basis herein; _____ other parent; or _____ both parents:
______________________________________________________________________________
.
If specified, the level of supervision shall be:__________________________________________.

16. Arrangements for Time-Sharing with Minor Child(ren).
{Initial all that apply; write N/A if does not apply}
a. _____A responsible person shall coordinate the time-sharing arrangements with respect to the
minor child(ren). If specified, the responsible person shall be: {name}

b. _____Other conditions for time-sharing arrangements as follows: ___________________

17. Exchange of Minor Child(ren).
{Initial all that apply; write N/A if does not apply}
a. _____The parties shall exchange the child(ren) at _____ school or daycare, or _____ at the
following location(s):

Florida Supreme Court Approved Family Law Form 12.980(d)(1), Final Judgment of Injunction for Protection
Against Domestic Violence with Minor Child(ren) (After Notice) (03/15)
- 513 -
b. _____A responsible person shall conduct all exchanges of the child(ren). The
_____ Petitioner _____ Respondent shall not be present during the exchange. If specified, the
responsible person shall be: {name}
__________________________________________________________________________ .

c. _____Other conditions for exchange as follows:

18. Other Additional Provisions Relating to the Minor Child(ren).

TEMPORARY SUPPORT

19. Temporary Alimony.
[Initial all that apply; write N/A if does not apply]
a. _____The court finds that there is a need for temporary alimony and that _____ Petitioner
_____ Respondent (hereinafter Obligor) has the present ability to pay alimony and shall pay temporary
alimony to ____ Petitioner ____ Respondent (hereinafter Obligee) in the amount of $_________ per
month, payable _____ in accordance with Obligor’s employer’s payroll cycle, and in any event, at least
once a month _____ other {explain}
beginning {date} _________________________. This alimony shall continue until modified
by court order, until a final judgment of dissolution of marriage is entered, until Obligee dies, until this
injunction expires, or until {date} _______________________, whichever occurs first.

b. _____ Petitioner _____ Respondent shall be required to maintain health insurance coverage
for the other party. Any uncovered medical costs for the party awarded alimony shall be assessed as
follows:
.

c. ______Other provisions relating to alimony:

20. Temporary Child Support.
{Initial all that apply; write N/A if does not apply}
a. _____The Court finds that there is a need for temporary child support and that
_____ Petitioner _____ Respondent (hereinafter Obligor) has the present ability to pay child support.

Florida Supreme Court Approved Family Law Form 12.980(d)(1), Final Judgment of Injunction for Protection
Against Domestic Violence with Minor Child(ren) (After Notice) (03/15)
- 514 -
The amounts in the Child Support Guidelines Worksheet, Florida Family Law Form 12.902(e), filed by
_____ Petitioner _____ Respondent are correct OR the Court makes the following findings:
The Petitioner’s net monthly income is $ __________, (Child Support Guidelines %).
The Respondent’s net monthly income is $ _________, (Child Support Guidelines %). Monthly
child care costs are $ __________________.
Monthly health/dental insurance costs are $________________.

b. _____Amount. Obligor shall pay temporary child support in the amount of $ _ ,
per month payable _____ in accordance with Obligor’s employer’s payroll cycle, and in any event at
least once a month _____other {explain}:__________________________________
,
beginning {date} ___________________, and continuing until further order of
the court, or until {date/event} _________________________________________________,
{explain} .
If the child support ordered deviates from the guidelines by more than 5%, the factual findings which
support that deviation are:
.

c. _____ Petitioner _____ Respondent shall be required to maintain ____ health ____ dental
insurance coverage for the parties’ minor child(ren) so long as it is reasonable in cost and
accessible to the child(ren) OR ____ Health ____ dental insurance is either not reasonable
in cost or accessible to the child(ren) at this time.

d. _____Any reasonable and necessary uninsured medical/dental/prescription drug costs for
the minor child(ren) shall be assessed as follows: ___________________________________
.

e. _____Florida Supreme Court Approved Family Law Form 12.902(j), Notice of Social Security
Number, is incorporated herein by reference.

f. _____Other provisions relating to child support:

21. Method of Payment.
[Initial one only]
a. ______ Obligor shall pay any temporary court-ordered child support/alimony through
income deduction, and such support shall be paid to either the State Disbursement Unit or the central
depository. Obligor is individually responsible for paying this support obligation in the event that all or
any portion of said support is not deducted from Obligor’s income. Obligor shall also pay any service
charge required by statute. Until child support/alimony payments are deducted from Obligor’s
paycheck pursuant to the Income Deduction Order, Obligor is responsible for making timely payments
directly to either the State Disbursement Unit or the central depository.

Florida Supreme Court Approved Family Law Form 12.980(d)(1), Final Judgment of Injunction for Protection
Against Domestic Violence with Minor Child(ren) (After Notice) (03/15)
- 515 -
b. ______ Temporary child support/alimony shall be paid through either the State
Disbursement Unit or the central depository. Obligor shall also pay any service charge required by
statute. Income deduction is not in the best interests of the child(ren) because: {explain}
_______________________________________________________________________ .

c. ______ Other provisions relating to method of payment:

SECTION IV. OTHER SPECIAL PROVISIONS
(This section to be used for inclusion of local provisions approved by the chief judge as provided in Florida
Family Law Rule 12.610.)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

2. THIS INJUNCTION IS ENFORCEABLE IN ALL COUNTIES OF FLORIDA, AND LAW ENFORCEMENT
OFFICERS MAY EFFECT ARRESTS PURSUANT TO SECTION 901.15(6), FLORIDA STATUTES. The
arresting agent shall notify the State Attorney's Office immediately after arrest.

3. Reporting alleged violations. If Respondent violates the terms of this injunction and there has
not been an arrest, Petitioner may contact the Clerk of the Circuit Court of the county in which
the violation occurred and complete an affidavit in support of the violation, or Petitioner may
contact the State Attorney’s office for assistance in filing an action for indirect civil contempt or
indirect criminal contempt. Upon receiving such a report, the State Attorney is hereby
appointed to prosecute such violations by indirect criminal contempt proceedings, or the State
Attorney may decide to file a criminal charge, if warranted by the evidence.

4. Respondent, upon service of this injunction, shall be deemed to have knowledge of and to be

5. The temporary injunction, if any, entered in this case is extended until such time as service of
this injunction is effected upon Respondent.

6. THIS IS A “CUSTODY ORDER” FOR PURPOSES OF THE UCCJEA AND ALL STATUTES MAKING IT A
CRIME TO INTERFERE WITH CUSTODY UNDER CHAPTER 787, FLORIDA STATUTES AND OTHER
SIMILAR STATUTES.
DONE AND ORDERED at __________________________, Florida, on .

__________________________________________
CIRCUIT JUDGE

Sheriff of _________________________County

Petitioner (or his or her attorney):
____ by U. S. Mail
____ by hand delivery in open court (Petitioner must acknowledge receipt in writing on the face of the
original order--see below.)
_____by e-mail to designated e-mail address(es)

Respondent (or his or her attorney):
___ _forwarded to sheriff for service
____ by hand delivery in open court (Respondent must acknowledge receipt in writing on the face of the
original order--see below.)
____ by certified mail (may only be used when Respondent is present at the hearing and Respondent
fails or refuses to acknowledge the receipt of a certified copy of this injunction.)

____ State Attorney’s Office
____ Batterer’s intervention program (if ordered)
___ _State Disbursement Unit (if ordered)
____Central Depository (if ordered)
____ Department of Revenue
____ Other __________________________________________________

I CERTIFY the foregoing is a true copy of the original Final Judgment of Injunction for Protection Against
Domestic Violence with Minor Child(ren) as it appears on file in the office of the Clerk of the Circuit
Court of ___________________ County, Florida, and that I have furnished copies of this order as
indicated above.
CLERK OF THE CIRCUIT COURT

ACKNOWLEDGMENT

I, {Name of Petitioner} , acknowledge receipt of a certified copy of this
Injunction for Protection.

Petitioner__________________________________________

ACKNOWLEDGMENT

I, {Name of Respondent} , acknowledge receipt of a certified
copy of this Injunction for Protection.

Respondent_________________________________________

Case No.:
Division:
_________________,
Petitioner,

and

_________________,
Respondent.

FINAL JUDGMENT OF INJUNCTION
FOR PROTECTION AGAINST DOMESTIC VIOLENCE
WITHOUT MINOR CHILD(REN) (AFTER NOTICE)

The Petition for Injunction for Protection Against Domestic Violence under Section 741.30, Florida
Statutes, and other papers filed in this Court have been reviewed. The Court has jurisdiction of the
parties and the subject matter.
It is intended that this protection order meet the requirements of 18 U.S.C. Section 2265 and
therefore intended that it be accorded full faith and credit by the court of another state or Indian tribe
and enforced as if it were the order of the enforcing state or of the Indian tribe.

SECTION I. HEARING

This cause came before the Court for a hearing to determine whether an Injunction for Protection
Against Domestic Violence in this case should be:
_____ issued_____ modified _____ extended.
The hearing was attended by:
_____ Petitioner
_____ Petitioner's Counsel
_____ Respondent
_____ Respondent’s Counsel

SECTION II. FINDINGS

Florida Supreme Court Approved Family Law Form 12.980(d)(2), Final Judgment of Injunction for Protection
Against Domestic Violence without Minor Child(ren) (After Notice) (03/15)
- 519 -
After hearing the testimony of each party present and of any witnesses, or upon consent of Respondent,
the Court finds, based on the specific facts of this case, that Petitioner is a victim of domestic violence or
has reasonable cause to believe that he/she is in imminent danger of becoming a victim of domestic
violence by Respondent.

SECTION III. INJUNCTION AND TERMS

This injunction shall be in full force and effect until ____ further order of the Court or ____
{date}___________________________. This injunction is valid and enforceable in all counties of the
State of Florida. The terms of this injunction may not be changed by either party alone or by both
parties together. Only the Court may modify the terms of this injunction. Either party may ask the
Court to change or end this injunction at any time.
Any violation of this injunction, whether or not at the invitation of Petitioner or anyone else, may
subject Respondent to civil or indirect criminal contempt proceedings, including the imposition of a
fine or imprisonment. Certain willful violations of the terms of this injunction, such as: refusing to
vacate the dwelling that the parties share; going to or being within 500 feet of Petitioner's residence,
going to Petitioner’s place of employment, school, or other place prohibited in this injunction;
telephoning, contacting or communicating with Petitioner if prohibited by this injunction; knowingly
or intentionally coming within 100 feet of Petitioner’s motor vehicle, whether or not it is occupied;
defacing or destroying Petitioner’s personal property; refusing to surrender firearms or ammunition if
ordered to do so by the court; or committing an act of domestic violence against Petitioner
constitutes a misdemeanor of the first degree punishable by up to one year in jail, as provided by
sections 775.082 and 775.083, Florida Statutes. In addition, it is a federal criminal felony offense,
punishable by up to life imprisonment, depending on the nature of the violation, to cross state lines or
enter Indian country for the purpose of engaging in conduct that is prohibited in this injunction. 18
U.S.C. Section 2262.

ORDERED and ADJUDGED:

1. Violence Prohibited. Respondent shall not commit, or cause any other person to commit, any
acts of domestic violence against Petitioner. Domestic violence includes: assault, aggravated assault,
battery, aggravated battery, sexual assault, sexual battery, stalking, aggravated stalking, kidnapping,
false imprisonment, or any other criminal offense resulting in physical injury or death to Petitioner or
any of Petitioner's family or household members. Respondent shall not commit any other violation of
the injunction through an intentional unlawful threat, word or act to do violence to the Petitioner.

Florida Supreme Court Approved Family Law Form 12.980(d)(2), Final Judgment of Injunction for Protection
Against Domestic Violence without Minor Child(ren) (After Notice) (03/15)
- 520 -
contact anyone connected with Petitioner's employment or school to inquire about Petitioner or to send
any messages to Petitioner. Unless otherwise provided herein, Respondent shall not go to, in, or within
500 feet of: Petitioner’s current residence {list address}

or any residence to which Petitioner may move; Petitioner’s current or any subsequent place of
employment {list address of current employment}
or place where Petitioner attends school {list address of school} ;
or the following other places (if requested by Petitioner) where Petitioner or Petitioner’s minor
child(ren) go often:

.
Respondent may not knowingly come within 100 feet of Petitioner's automobile at any time.

b. Other provisions regarding contact: _______________________________________________

3. Firearms. Unless paragraph a. is initialed below, Respondent shall not have in his or her care,
custody, possession or control any firearm or ammunition. It is a violation of Section 790.233, Florida
Statutes, and a first degree misdemeanor, for the Respondent to have in his or her care, custody,
possession or control any firearm or ammunition.

{Initial if applies; write N/A if not applicable}
a. ____Respondent is a state or local officer as defined in section 943.10(14), Florida Statutes,
who holds an active certification, who receives or possesses a firearm or ammunition for use
in performing official duties on behalf of the officer’s employing agency and is not
prohibited by the court from having in his or her care, custody, possession or control a
firearm or ammunition. The officer’s employing agency may prohibit the officer from having
in his or her care, custody, possession or control a firearm or ammunition.

b. ____Respondent shall surrender any firearms and ammunition in the Respondent's
possession to the County Sheriff's Department.

c. ____Other directives relating to firearms and ammunition:

Florida Supreme Court Approved Family Law Form 12.980(d)(2), Final Judgment of Injunction for Protection
Against Domestic Violence without Minor Child(ren) (After Notice) (03/15)
- 521 -
4. Evaluation/Counseling.
{Initial all that apply; write N/A if does not apply}
a. The Court finds that Respondent has:
i. ____willfully violated the ex parte injunction;

ii. ____been convicted of, had adjudication withheld on, or pled nolo contendere to a crime
involving violence or a threat of violence; and/or

iii. ____in this state or any other state, had at any time a prior injunction for protection entered
against the respondent after a hearing with notice.

b. Within ____10 days ____ days, (but no more than 10 days) of the date of this injunction, Respondent
shall enroll in and thereafter without delay complete the following, and Respondent shall provide proof
of such enrollment to the Clerk of Circuit Court within ____ 30 days _____ days, (but no more than 30
days) of the date of this injunction:
i. ____A certified batterers’ intervention program from a list of programs to be provided
by the Court or any entity designated by the Court. Respondent shall also successfully
complete any substance abuse or mental health evaluation that the assessing program
counselor deems necessary as a predicate to completion of the batterers’ intervention
program.

ii. ____A substance abuse evaluation at:
or a similarly qualified facility and any substance abuse treatment recommended by that
evaluation.

iii. ____A mental health evaluation by a licensed mental health professional at:
_______________________or any other similarly qualified facility and any mental
health treatment recommended by that evaluation.

iv. ____Other:

c. ____Although Respondent meets the statutory mandate of attendance at a batterers’
intervention program, the Court makes the following written findings as to why the condition of
batterers’ intervention program would be inappropriate:

Florida Supreme Court Approved Family Law Form 12.980(d)(2), Final Judgment of Injunction for Protection
Against Domestic Violence without Minor Child(ren) (After Notice) (03/15)
- 522 -
d. ____Petitioner is referred to a certified domestic violence center and is provided with a list
of certified domestic violence centers in this circuit, which Petitioner may contact.

5. Mailing Address or Designated E-Mail Address(es). Respondent shall notify the Clerk of the
Court of any change in either his or her mailing address, or designated e-mail address(es), within 10 days
of the change. All further papers (excluding pleadings requiring personal service) shall be served either
by mail to Respondent’s last known mailing address or by e-mail to Respondent’s designated e-mail
address(es). Service shall be complete upon mailing or emailing.

6. Other provisions necessary to protect Petitioner from domestic violence:

9. ____Personal Items. ____ Petitioner ____ Respondent, in the presence of a law enforcement
officer, may return to the premises described above
____ on __, at ______a.m./p.m., or
____ at a time arranged with the law enforcement department with jurisdiction over the home,
accompanied by a law enforcement officer only, for the purpose of obtaining his or her clothing and
items of personal health and hygiene and tools of the trade. A law enforcement officer with jurisdiction
over the premises shall go with ____ Petitioner ____Respondent to the home and stand by to insure
that he/she vacates the premises with only his/her personal clothing, toiletries, tools of the trade, and
any items listed in paragraph 10 below. The law enforcement agency shall not be responsible for storing
or transporting any property. IF THE RESPONDENT IS NOT AWARDED POSSESSION OF THE HOME AND
GOES TO THE HOME WITHOUT A LAW ENFORCEMENT OFFICER, IT IS A VIOLATION OF THIS
INJUNCTION.

10. ____The following other personal possessions may also be removed from the premises at this
time:

Florida Supreme Court Approved Family Law Form 12.980(d)(2), Final Judgment of Injunction for Protection
Against Domestic Violence without Minor Child(ren) (After Notice) (03/15)
- 523 -
.

11. ____Other:_____________________________________________________________________

TEMPORARY SUPPORT

12. Temporary Alimony.
{Initial all that apply; write N/A if does not apply}
a. ____The court finds that there is a need for temporary alimony and that ____ Petitioner
____Respondent (hereinafter Obligor) has the present ability to pay alimony and shall pay temporary
alimony to ____ Petitioner ____ Respondent (hereinafter Obligee) in the amount of per month, payable
____ in accordance with Obligor’s employer’s payroll cycle, and in any event, at least once a month ____
other {explain}

beginning {date} _____________. This alimony shall continue until modified by
court order, until a final judgment of dissolution of marriage is entered, until Obligee dies, until this
injunction expires, or until {date} ___, whichever occurs first.

b. ____The _____ Petitioner _____ Respondent shall be required to maintain health insurance
coverage for the other party. Any uncovered medical costs for the party awarded alimony shall be
assessed as follows: .
c. ____Other provisions relating to alimony:

________________________________________
13. Method of Payment.
[Initial one only]
a. ____Obligor shall pay any temporary court-ordered alimony through income deduction, and
such support shall be paid to either the State Disbursement Unit or the central depository. Obligor is
individually responsible for paying this support obligation in the event that all or any portion of said
support is not deducted from Obligor’s income. Obligor shall also pay any service charge required by
statute. Until alimony payments are deducted from Obligor’s paycheck pursuant to the Income
Deduction Order, Obligor is responsible for making timely payments directly to either the State
Disbursement Unit or the central depository.

b. ____Temporary alimony shall be paid through either the State Disbursement Unit or the
central depository. Obligor shall also pay any applicable service charge required by statute.

c. ____Other provisions relating to method of payment:
_________________________________

Florida Supreme Court Approved Family Law Form 12.980(d)(2), Final Judgment of Injunction for Protection
Against Domestic Violence without Minor Child(ren) (After Notice) (03/15)
- 524 -
.

SECTION IV. OTHER SPECIAL PROVISIONS
{This section to be used for inclusion of local provisions approved by the chief judge as provided in Florida
Family Law Rule 12.610.}
________________________________________________________________
___________________
________________________________________________________________
___________________
________________________________________________________________
___________________ .

SECTION V. DIRECTIONS TO LAW ENFORCEMENT OFFICER IN ENFORCING
THIS INJUNCTION
{Unless ordered otherwise by the judge, all provisions in this injunction are
considered mandatory provisions and should be interpreted as part of this
injunction.}

1. This injunction is valid in all counties of the State of Florida. Violation
of this injunction should be reported to the appropriate law enforcement
agency. Law enforcement officers of the jurisdiction in which a violation of this
injunction occurs shall enforce the provisions of this injunction and are
authorized to arrest without warrant pursuant to section 901.15, Florida
Statutes, for any violation of its provisions, except those regarding child
support and/or alimony, which constitutes a criminal act under section 741.31,
Florida Statutes. When inconsistent with this order, any subsequent court
order issued under Chapter 61, Florida Statutes, shall take precedence over
this order on all matters relating to property division, alimony, child custody,
or child support.
2. THIS INJUNCTION IS ENFORCEABLE IN ALL COUNTIES OF FLORIDA, AND
LAW ENFORCEMENT OFFICERS MAY EFFECT ARRESTS PURSUANT TO SECTION
901.15(6), FLORIDA STATUTES. The arresting agent shall notify the State
Attorney's Office immediately after arrest.
3. Reporting alleged violations. If Respondent violates the terms of this
injunction and there has not been an arrest, Petitioner may contact the Clerk of
the Circuit Court of the county in which the violation occurred and complete an
affidavit in support of the violation, or Petitioner may contact the State
Attorney’s office for assistance in filing an action for indirect civil contempt or
indirect criminal contempt. Upon receiving such a report, the State Attorney is
hereby appointed to prosecute such violations by indirect criminal contempt

Florida Supreme Court Approved Family Law Form 12.980(d)(2), Final Judgment of Injunction for Protection
Against Domestic Violence without Minor Child(ren) (After Notice) (03/15)
- 525 -
proceedings, or the State Attorney may decide to file a criminal charge, if
warranted by the evidence.
4. Respondent, upon service of this injunction, shall be deemed to have
knowledge of and to be bound by all matters occurring at the hearing and on
the face of this injunction.
5. The temporary injunction, if any, entered in this case is extended until
such time as service of this injunction is effected upon Respondent.

DONE AND ORDERED in ____________________, Florida on ______.

_______________________________________
CIRCUIT JUDGE

Sheriff of County

Florida Supreme Court Approved Family Law Form 12.980(d)(2), Final Judgment of
Injunction for Protection Against Domestic Violence without Minor Child(ren) (After
Notice) (03/15)
- 526 -
I CERTIFY that a copy of the original Final Judgment of Injunction for Protection Against Domestic
Violence without Minor Child(ren) was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-
delivered to the parties and any entities listed below on {date}________________.

CLERK OF THE CIRCUIT COURT
(SEAL)
By:
Deputy Clerk or Judicial Assistant

Sheriff of County

Petitioner (or his or her attorney):
____ by U. S. Mail
____ by hand delivery in open court (Petitioner must acknowledge receipt in writing on the face of the
original order--see below.)

ACKNOWLEDGMENT

__________________________________
Petitioner

ACKNOWLEDGMENT

I, {Name of Respondent} , acknowledge receipt of a certified
copy of this Injunction for Protection.

____________________________________
Respondent

Case No.:
Division:
___________________,
Petitioner,
and

____________________,
Respondent.

ORDER OF DISMISSAL OF TEMPORARY INJUNCTION FOR PROTECTION
AGAINST ( ) DOMESTIC VIOLENCE ( ) REPEAT VIOLENCE
( ) DATING VIOLENCE ( ) SEXUAL VIOLENCE ( ) STALKING

THIS CAUSE came before the Court on {date} , upon Petitioner’s action for an
injunction for protection against: domestic violence; repeat, dating, or sexual violence; or stalking.
Based upon the following circumstances, the Court dismisses the Petition:

{Indicate all that apply}

a. __ Petitioner failed to appear at the hearing scheduled in this cause.

b. __ Petitioner appeared at the hearing but desires to voluntarily dismiss this action.

c. __ The evidence presented is insufficient under Florida law (sections 741.30, 784.046, or
784.0485, Florida Statutes) to allow the Court to issue an injunction for protection against
domestic, repeat, dating, or sexual violence; or stalking.

Accordingly, the case is dismissed without prejudice.

DONE AND ORDERED in___________________________, Florida on .

CIRCUIT JUDGE

Sheriff of _________________ County

Petitioner:
_____by U.S. Mail
_____ by hand delivery in open court
_____ by e-mail to designated e-mail address(es)

Respondent:
_____by U.S. Mail
_____by hand delivery in open court
_____ by e-mail to designated e-mail address(es)

_____State’s Attorney’s Office

_____Other: ________________________________

I CERTIFY the foregoing is a true copy of the original Order of Dismissal of Temporary Injunction as it
appears on file in the office of the Clerk of the Circuit Court of ___________________ County, Florida,
and that I have furnished copies of this order as indicated above.

CLERK OF THE CIRCUIT COURT
(SEAL)
By:
{Deputy Clerk or Judicial Assistant}

Florida Supreme Court Approved Family Law Form 12.980(e), Order of Dismissal of Temporary Injunction for
Protection Against Domestic Violence, Repeat Violence, Dating Violence, Sexual Violence, or Stalking (03/15)
- 530 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.980(f)
PETITION FOR INJUNCTION FOR
PROTECTION AGAINST REPEAT VIOLENCE (03/15)

When should this form be used?

If you or a member of your immediate family are a victim of repeat violence, you can use this form to
ask the court for a protective order prohibiting repeat violence. Repeat violence means that two
incidents of violence have been committed against you or a member of your immediate family by
another person, one of which must have been within 6 months of filing this petition. Repeat violence
includes assault, aggravated assault, battery, aggravated battery, sexual assault, sexual battery, stalking,
aggravated stalking, kidnapping, or false imprisonment, or any criminal offense resulting in physical
injury or death. Because you are making a request to the court, you are called the petitioner. The
person whom you are asking the court to protect you from is called the respondent. If you are under
the age of eighteen and have never been married or had the disabilities of nonage removed by a court,
one of your parents or your legal guardian must sign this petition on your behalf.

The parent or legal guardian of any minor child who is living at home may seek an injunction for
protection against repeat violence on behalf of the minor child. With respect to a minor child who is
living at home, the parent or legal guardian must have been an eye-witness to, or have direct physical
evidence or affidavits from eye-witnesses of, the specific facts and circumstances that form the basis of
the petition.

If the respondent is your spouse, former spouse, related to you by blood or marriage, living with you
now or has lived with you in the past (if you are or were living as a family), or the other parent of your
child(ren), whether or not you have ever been married or ever lived together, you should use Petition
for Injunction for Protection Against Domestic Violence, Florida Supreme Court Approved Family Law
Form 12.980(a), rather than this form.

This form should be typed or printed in black ink. You should complete this form (giving as much detail
as possible) and sign it the presence of a notary or in front of the clerk of the circuit court in the county
where you live. The clerk will take your completed petition to a judge. You should keep a copy for your
records. If have any questions or need assistance completing this form, the clerk or family law intake
staff will help you.

What should I do if the judge grants my petition?

If the facts contained in your petition convince the judge that you or a member of your immediate
family are a victim of repeat violence and that an immediate and present danger of repeat violence to
you or that family exists, the judge will sign a Temporary Injunction for Protection Against Repeat

Instructions for Florida Supreme Court Approved Family Law Form 12.980(f), Petition for Injunction for Protection
Against Repeat Violence (03/15)
- 531 -
Violence, Florida Supreme Court Approved Family Law Form 12.980(k). A temporary injunction is issued
without notice to the respondent. The clerk will give your petition, the temporary injunction, and any
other papers filed with your petition to the sheriff or other law enforcement officer for personal service
on the respondent. The temporary injunction will take effect immediately after the respondent is served
with a copy of it. It lasts until a full hearing can be held or for a period of 15 days, whichever comes first.
The court may extend the temporary injunction beyond 15 days for a good reason, which may include
failure to obtain service on the respondent.

The temporary injunction is issued ex parte. This means that the judge has considered only the
information presented by one side--YOU. Section I of the temporary injunction gives a date that you
should appear in court for a hearing. You will be expected to testify about the facts in your petition. The
respondent will be given the opportunity to testify at this hearing, also. At the hearing, the judge will
decide whether to issue a Final Judgment of Injunction for Protection Against Repeat Violence (After
Notice), Florida Supreme Court Approved Family Law Form 12.980(l), which will remain in effect for a
specific time period or until modified or dissolved by the court. If you and/or the respondent do not
appear, the temporary injunction may be continued in force, extended, or dismissed, and/or
additional orders may be granted, including entry of a permanent injunction and the imposition of
court costs. You and respondent will be bound by the terms of any injunction or order issued at the
final hearing.

IF EITHER YOU OR RESPONDENT DO NOT APPEAR AT THE FINAL HEARING, YOU WILL BOTH BE BOUND
BY THE TERMS OF ANY INJUNCTION OR ORDER ISSUED IN THIS MATTER.

If the judge signs a temporary or final injunction, the clerk will provide you with the necessary copies.
Make sure that you keep one certified copy of the injunction with you at all times!

What can I do if the judge denies my petition?

If your petition is denied on the grounds that it appears to the court that no immediate and present
danger of repeat violence exists, the court will set a full hearing on your petition. The respondent will
be notified by personal service of your petition and the hearing. If your petition is denied, you may:
amend your petition by filing a Supplemental Affidavit in Support of Petition for Injunction for
Protection, Florida Supreme Court Approved Family Law Form 12.980(g); attend the hearing and
present facts that support your petition; and/or dismiss your petition.

Where can I look for more information?

Instructions for Florida Supreme Court Approved Family Law Form 12.980(f), Petition for Injunction for Protection
Against Repeat Violence (03/15)
- 532 -
IMPORTANT INFORMATION REGARDING E-FILING

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions for Florida Supreme Court Approved Family Law Form 12.980(f), Petition for Injunction for Protection
Against Repeat Violence (03/15)
- 533 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR ____________ COUNTY, FLORIDA

Case No.:
Division:
_________________ ,
Petitioner,
and

__________________,
Respondent.

PETITION FOR INJUNCTION FOR PROTECTION
AGAINST REPEAT VIOLENCE
I, {full legal name} , being sworn, certify that the
following statements are true:

SECTION I. PETITIONER
(This section is about you. It must be completed.)

1. Petitioner currently lives at the following address: {address, city, state, zip code}
.
[Indicate if applicable]
__Petitioner seeks an injunction for protection on behalf of a minor child. Petitioner is the parent
or legal guardian of {full legal name} ___________________, a minor child who is
living at home.

2. Petitioner's attorney's name, address, and telephone number is:
.
(If you do not have an attorney, write "none.")

SECTION II. RESPONDENT
(This section is about the person you want to be protected from. It must be completed.)

1. Respondent currently lives at the following address: {address, city, state, and zip code}
.
Respondent’s Driver’s License number is: {if known} .

2. Petitioner has known Respondent since: {date} .

Florida Supreme Court Approved Family Law Form 12.980(f), Petition for Injunction for Protection Against Repeat
Violence (03/15)
- 534 -
3. Respondent's last known place of employment:
Employment address:
Working hours:

4. Physical description of Respondent:
Race: Sex: Male _ Female Date of Birth: _________________________
Height: Weight: Eye Color: Hair Color:
Distinguishing marks and/or scars:
Vehicle: (make/model) Color: Tag Number: __________________

5. Other names Respondent goes by (aliases or nicknames):

6. Respondent's attorney’s name, address, and telephone number is:
.
(If you do not know whether Respondent has an attorney, write "unknown." If Respondent does not
have an attorney, write "none.")

SECTION III. CASE HISTORY AND REASON FOR SEEKING PETITION (This section must be completed.)

1. Has Petitioner ever received or tried to get an injunction for protection against domestic
violence, repeat violence, dating violence, or sexual violence against Respondent in this or any other
court?
__ Yes __ No If yes, what happened in that case? {include case number, if known}

2. Has Respondent ever received or tried to get an injunction for protection against domestic
violence, repeat violence, dating violence, or sexual violence against Petitioner in this or any other
court?
__ Yes __ No If yes, what happened in that case? {include case number, if known}

________________________________________________________________________

3. Describe any other court case that is either going on now or that happened in the past between
Petitioner and Respondent {include case number, if known}:

4. Respondent has directed at least two incidents of violence, meaning assault, aggravated assault,
battery, aggravated battery, sexual assault, sexual battery, stalking, aggravated stalking, kidnapping, or
false imprisonment, or any criminal offense resulting in physical injury or death against Petitioner or a
member of Petitioner’s immediate family. One of these two incidents of violence has occurred within 6
months of the date of filing of this petition. The most recent incident (including date and location) is

Florida Supreme Court Approved Family Law Form 12.980(f), Petition for Injunction for Protection Against Repeat
Violence (03/15)
- 535 -
described below.

On {date} , at {location} ,
Respondent

.
______Please indicate here if you are attaching additional pages to continue these facts.

5. Other prior incidents (including dates and location) are described below:

On {date} , at {location} ,
Respondent

.
_____Please indicate here if you are attaching additional pages to continue these facts.

6. Petitioner genuinely fears repeat violence by Respondent. Explain:

7. Additional Information

Florida Supreme Court Approved Family Law Form 12.980(f), Petition for Injunction for Protection Against Repeat
Violence (03/15)
- 536 -
[Choose all that apply]
a. ____Respondent owns, has, and/or is known to have guns or other weapons.
Describe weapon(s):
.

b. ____This or prior acts of repeat violence have been previously reported to: {person or
agency}
.

SECTION IV. INJUNCTION (This section must be completed.)

1. ____Petitioner asks the Court to enter a TEMPORARY INJUNCTION for protection against repeat
violence that will be in place from now until the scheduled hearing in this matter.

2. ____Petitioner asks the Court to enter, after a hearing has been held on this petition, a final
judgment of injunction prohibiting Respondent from committing any acts of violence against Petitioner
and:
a. prohibiting Respondent from going to or within 500 feet of any place Petitioner lives;

b. prohibiting Respondent from going to or within 500 feet of Petitioner’s place(s) of
employment or the school that Petitioner attends; the address of Petitioner's place(s) of employment
and/or school is:
;

c. prohibiting Respondent from contacting Petitioner by telephone, mail, by e-mail, in writing,
through another person, or in any other manner;

d. ordering Respondent not to use or possess any guns or firearms;

[Indicate all that apply]
e. ____ prohibiting Respondent from going to or within 500 feet of the following place(s)
Petitioner or Petitioner’s immediate family must go to often:
________________________________________________________________________ .

f. ____ prohibiting Respondent from knowingly and intentionally going to or within 100 feet of
Petitioner’s motor vehicle; and any other terms the Court deems necessary for the safety of Petitioner
and Petitioner’s immediate family.

I UNDERSTAND THAT BY FILING THIS PETITION, I AM ASKING THE COURT TO HOLD A HEARING ON
THIS PETITION, THAT BOTH THE RESPONDENT AND I WILL BE NOTIFIED OF THE HEARING, AND THAT I
MUST APPEAR AT THE HEARING. I UNDERSTAND THAT IF EITHER RESPONDENT OR I FAIL TO APPEAR
AT THE FINAL HEARING, WE WILL BE BOUND BY THE TERMS OF ANY INJUNCTION OR ORDER ISSUED

Florida Supreme Court Approved Family Law Form 12.980(f), Petition for Injunction for Protection Against Repeat
Violence (03/15)
- 537 -
AT THAT HEARING.

I UNDERSTAND THAT I AM SWEARING OR AFFIRMING UNDER OATH TO THE TRUTHFULNESS OF THE
CLAIMS MADE IN THIS PETITION AND THAT THE PUNISHMENT FOR KNOWINGLY MAKING A FALSE
STATEMENT INCLUDES FINES AND/OR IMPRISONMENT.

Dated: _______________
Signature of Petitioner

Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:

Designated E-Mail Address(es): __________________________________________

STATE OF FLORIDA
COUNTY OF .

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

{Print, type, or stamp commissioned name of notary or clerk}
__ Personally known
__ Produced identification
Type of identification produced

Florida Supreme Court Approved Family Law Form 12.980(f), Petition for Injunction for Protection Against Repeat
Violence (03/15)
- 538 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.980(g)
SUPPLEMENTAL AFFIDAVIT IN SUPPORT OF PETITION FOR INJUNCTION
FOR PROTECTION AGAINST DOMESTIC, REPEAT, DATING, OR SEXUAL
VIOLENCE, OR STALKING (03/15)

When should this form be used?

You may use this form if your Petition for Injunction for Protection Against Domestic Violence, Florida
Supreme Court Approved Family Law Form 12.980(a), your Petition for Injunction for Protection
Against Repeat Violence, Florida Supreme Court Approved Family Law Form 12.980(f), your Petition for
Injunction for Protection Against Dating Violence, Florida Supreme Court Approved Family Law Form
12.980(n), your Petition for Injunction for Protection Against Sexual Violence, Florida Supreme Court
Approved Family Law Form 12.890(q), or your Petition for Injunction for Protection Against Stalking,
Florida Supreme Court Approved Family Law Form 12.980(t),was denied by the judge.

You should use this supplemental affidavit to add facts or clarify the facts you wrote in your original
petition.

For a domestic violence case, you should include facts that establish that you have been a victim of
violence or are in imminent danger of becoming a victim of violence from the respondent.

For a repeat violence case, you should include facts that establish that you or a member of your
immediate family have or has been a victim of at least two prior incidents of violence, that one of those
incidents occurred within the last six months and that there is an immediate and present risk of danger
to you or a member of your immediate family.

For a dating violence case, you should include fact that establish that you have been a victim of violence
or are in imminent danger of becoming a victim of violence from the respondent who is an individual
with whom you have or have had a continuing and significant relationship of a romantic or intimate
nature, to be determined by consideration of such facts as: whether the dating relationship existed
within the past six months; whether the nature of the relationship included an expectation of affection
or sexual involvement; and whether the frequency and type of interaction between you and the
individual included involvement over time and on a continued basis. Dating violence does not include
violence in a casual acquaintanceship or violence between individuals who have only engaged in
ordinary fraternization in a business or social context.

For a sexual violence case, you should include facts that establish that you are a victim of sexual violence
or the parent of a minor child living at home who is a victim of sexual violence, and that you have
reported the sexual violence to law enforcement and are cooperating in the criminal proceeding if there
is one. If the respondent was in state prison for sexual violence against you or the minor child and the

Instructions for Florida Supreme Court Approved Family Law Form 12.980(g), Supplemental Affidavit in Support of
Petition for Injunction for Protection Against Domestic, Repeat, Dating, or Sexual Violence, or Stalking (03/15)
- 539 -
respondent is out of prison or is getting out within 90 days of the petition, include that information in
your supplemental affidavit, along with a copy of the notice of inmate release.
For a stalking case, you should include facts that establish that you are either a victim of stalking or
cyberstalking, or that you are the parent or legal guardian of a minor child living at home who is a victim
of stalking or cyberstalking. The facts must establish that stalking exists in order for the judge to order a
temporary injunction for protection against stalking. Please be specific as to where the incidents of
stalking took place. These locations may include, but need not be limited to, a home, school, or place of
employment. For cyberstalking, please include a description of all evidence of contacts and/or threats
made by the respondent in voice messages, texts, emails, or other electronic communication.

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?

After you complete this supplemental affidavit, the clerk will attach it to your original petition and all the
documents will be submitted to the judge as your Amended Petition.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions for Florida Supreme Court Approved Family Law Form 12.980(g), Supplemental Affidavit in Support of
Petition for Injunction for Protection Against Domestic, Repeat, Dating, or Sexual Violence, or Stalking (03/15)
- 540 -
Please CAREFULLY read the rules and instructions for: Certificate of Service (General), Florida Supreme
Court Approved Family Law Form 12.914; Designation of Current Mailing and E-mail Address, Florida
Supreme Court Approved Family Law Form 12.915; and Florida Rule of Judicial Administration 2.516.

Instructions for Florida Supreme Court Approved Family Law Form 12.980(g), Supplemental Affidavit in Support of
Petition for Injunction for Protection Against Domestic, Repeat, Dating, or Sexual Violence, or Stalking (03/15)
- 541 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR ____________ COUNTY, FLORIDA

Case No.:
Division:
_________,
Petitioner,
and

________,
Respondent.

SUPPLEMENTAL AFFIDAVIT IN SUPPORT OF PETITION FOR
INJUNCTION FOR PROTECTION AGAINST
( ) DOMESTIC VIOLENCE ( ) REPEAT VIOLENCE
( ) DATING VIOLENCE ( ) SEXUAL VIOLENCE ( ) STALKING

I, {full legal name} , being sworn, certify that the
following statements are true:
{Please complete all paragraphs that relate to your case}

1. On {date} , at {place and address}
,
Respondent said or did the following things that hurt me or a member of my immediate family and
made me afraid for my or my family member’s safety:

.
_____Please indicate here if you are attaching additional pages to continue these facts.

.
____ Please indicate here if you are attaching additional pages to continue these facts.

3. On {date} ________________ the following incidents of stalking occurred at the following
locations: {the locations may include, but need not be limited to, a home, school, or place of
employment} _______________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________ .
For cyberstalking, the following is a description of all evidence of contacts and/or threats made
by Respondent in voice messages, texts, emails, or other electronic communication: ________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
______________________________________________________________________________ .
____ Please indicate here if you are attaching additional pages to continue these facts.

4. __Please indicate here if you are attaching copies of medical records for treatment you may
have received for injuries referred to in your petition or in this supplemental affidavit, copies of any
police or sheriff reports concerning incidents of violence involving you and Respondent, or any notice of
inmate release.

Florida Supreme Court Approved Family Law Form 12.980(g), Supplemental Affidavit in Support of Petition for
Injunction for Protection Against Domestic, Repeat, Dating, or Sexual Violence, or Stalking (03/15)
- 543 -
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
supplemental affidavit and that the punishment for knowingly making a false statement includes fines
and/or imprisonment.

Dated:

______________________________________
Signature of Petitioner

STATE OF FLORIDA
COUNTY OF

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

{Print, type, or stamp commissioned name of notary or clerk}

__ Personally known
__ Produced identification
Type of identification produced

Florida Supreme Court Approved Family Law Form 12.980(g), Supplemental Affidavit in Support of Petition for
Injunction for Protection Against Domestic, Repeat, Dating, or Sexual Violence, or Stalking (03/15)
- 544 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.980(h)
REQUEST FOR CONFIDENTIAL FILING OF ADDRESS (03/15)
When should this form be used?

IMPORTANT INFORMATION REGARDING E-FILING

Instructions for Florida Supreme Court Approved Family Law Form 12.980(h), Request for Confidential Filing of
Address (03/15)
- 545 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
___________________,
Petitioner,
and

___________________,
Respondent.

REQUEST FOR CONFIDENTIAL FILING OF ADDRESS

I, {full legal name} , request that the Court
maintain and hold as confidential, the following address:

Address

City State Zip
Telephone (area code and number)

This request is being made for the purpose of keeping the location of my residence unknown for safety
reasons pursuant to section 119.071(2)(j)1, section 784.0485(3)(b)1, Florida Statutes, or other statutory
provision providing for the separate confidential filing for safety reasons.

Dated: __________________________________________
Signature

CLERK’S CERTIFICATE AS TO REQUEST FOR
CONFIDENTIAL FILING OF ADDRESS

I, , as Clerk of the Circuit Court, do hereby certify that I
received and filed the above and will keep the above address confidential, subsequent to further order
of the Court relative to such confidentiality.

CLERK OF THE CIRCUIT COURT
(SEAL)

By:
{Deputy Clerk}

Florida Supreme Court Approved Family Law Form 12.980(h), Request for Confidential Filing of Address
(03/15)
- 546 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.980(i)
MOTION FOR EXTENSION OF INJUNCTION FOR PROTECTION AGAINST
DOMESTIC, REPEAT, DATING, OR SEXUAL VIOLENCE, OR STALKING
(03/15)

When should this form be used?

If you are the petitioner on a previously entered injunction for protection against domestic violence,
repeat violence, dating violence, sexual violence, or stalking, and that injunction will soon expire, you
may use this form to request that the court extend the injunction. You must file a motion for
extension BEFORE the previously entered order expires.

This form should be typed or printed in black ink. After completing this form, you should sign it before a
notary public or the clerk of the circuit court. You should then file the original with the clerk in the
county where the petition was filed and keep a copy for your records. If you have any questions or need
assistance completing this form, the clerk or family law intake staff will help you.

What should I do next?

For your case to proceed, you will need to set a hearing on your motion. You must properly notify the
other party of the motion and hearing. You should check with the clerk of court for information on the
local procedure for scheduling a hearing. When you know the date and time of your hearing, you should
file Notice of Hearing (General), Florida Supreme Court Approved Family Law Form 12.923, or other
appropriate notice of hearing form. You will need to serve a copy of your motion and Notice of Hearing
on the other party by U.S. mail, e-mail, or hand delivery. Service of your motion must be in in a manner
that is reasonably calculated to apprise the other party of your motion and the hearing. Please note that
if notice is mailed or e-mailed, the court in certain circumstances may not consider mailing or e-mailing
to be adequate notice. If you want to be sure, you should consider using certified mail, return receipt
requested, or having the motion personally served. This is a technical area of the law; if you have any
questions about it, you should consult a lawyer. For more information on personal service, see the
instructions for Summons: Personal Service on an Individual, Florida Family Law Rules of Procedure
Form 12.910(a).

You will need to appear at the hearing on your motion. After the hearing, if the judge grants your
motion, he or she will prepare an Order Extending Injunction for Protection Against Domestic Violence,
Repeat Violence, Dating Violence, or Sexual Violence, or Stalking, Florida Supreme Court Approved
Family Law Form 12.980(m). After the judge signs the order, the clerk will provide you with the
necessary copies. Make sure that you keep a certified copy of the previously entered injunction AND a
certified copy of the order extending that injunction with you at all times.

IMPORTANT INFORMATION REGARDING E-FILING

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Special notes...

With this form you may also file a Request for Confidential Filing of Address, Florida Supreme Court
Approved Family Law Form 12.980(h), if you fear that disclosing your address would put you in danger
because you are the victim of sexual battery, aggravated child abuse, stalking, aggravated stalking,
harassment, aggravated battery, or domestic violence, and you wish to keep your address confidential.

Instructions for Florida Supreme Court Approved Family Law Form 12.980(i), Motion for Extension of Injunction for
Protection Against Domestic, Repeat , Dating or Sexual Violence; or Stalking (03/15)
- 548 -
When completing this form, you should make sure that your reasons for requesting that the injunction
be extended are stated clearly and that you include all relevant facts.

Instructions for Florida Supreme Court Approved Family Law Form 12.980(i), Motion for Extension of Injunction for
Protection Against Domestic, Repeat , Dating or Sexual Violence; or Stalking (03/15)
- 549 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR ____________ COUNTY, FLORIDA

Case No.:

Division:
___________,
Petitioner,
and

____________,
Respondent.

MOTION FOR EXTENSION OF INJUNCTION FOR PROTECTION AGAINST
( ) DOMESTIC VIOLENCE ( ) REPEAT VIOLENCE
( ) DATING VIOLENCE ( ) SEXUAL VIOLENCE ( ) STALKING
I, {full legal name} , being sworn, certify that the following
statements are true:

SECTION I. PETITIONER
(This section is about you. It must be completed; however, if you fear that disclosing your address
would put you in danger because you are the victim of sexual battery, aggravated child abuse,
stalking, aggravated stalking, harassment, aggravated battery, or domestic violence, you should
complete and file a Request for Confidential Filing of Address, Florida Supreme Court Approved Family
Law Form 12.980(h), and write "confidential" in the space provided on this form for your address and
telephone number.)

1. Petitioner currently lives at the following address: {street address}
{city, state, and zip code}
Telephone Number: {area code and number}

2. Petitioner's attorney's name, address and telephone number is:
.
(If you do not have an attorney, write "none.")

SECTION II. RESPONDENT
(This section is about the person you want to be protected from. It must be completed.)

New information about Respondent, since the current injunction was issued: (If known, write
Respondent’s new address, place of employment, physical description, vehicle, aliases or nicknames, or

___________________________________________

SECTION III. CASE HISTORY AND REASON FOR SEEKING EXTENSION OF INJUNCTION

1. Describe any attempts since the date of the current injunction by either Petitioner or
Respondent to get an injunction for protection in this or any other court (other than the injunction you
are asking to extend in this motion).

2. Describe any other court cases (including city, state, and case numbers, if known) since the date
of the current injunction between Petitioner and Respondent, including any cases involving the parties'
minor child(ren), divorce, juvenile dependency, guardianship, or other civil or criminal cases.

3. Petitioner requests that the previously entered injunction for protection against domestic
violence, repeat violence, dating violence, sexual violence, or stalking, be extended for the following
specific reasons: {State in detail why you wish the injunction to remain in effect.}

.
______Please indicate here if you are attaching additional pages to continue these facts.

4. Petitioner genuinely fears the continued threat of violence or stalking by Respondent.

SECTION IV. REQUESTED RELIEF

1. Petitioner understands that the Court will hold a hearing on this motion and that he or she must
appear at the hearing.

Florida Supreme Court Approved Family Law Form 12.980(i), Motion for Extension of Injunction for Protection
Against Domestic, Repeat, Dating or Sexual Violence; or Stalking (03/15)
- 551 -
2. Petitioner asks the Court to enter an order in this case that extends the previously entered
injunction for a period of ( ) or ( ) until modified or dissolved by the court.

I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed
( ) mailed by certified mail, return receipt requested, ( ) furnished to a law enforcement officer for
personal service to the person(s) listed below on {date} .

Other party or his/her attorney:
Name:
Address:
City, State, Zip:
Fax Number:
Designated E-Mail Address(es):______________
_______________________________________

Dated: ______

Signature of Petitioner

STATE OF FLORIDA
COUNTY OF

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

{Print, type, or stamp commissioned name of notary or clerk}
_____ Personally known
___ Produced identification
Type of identification produced

Florida Supreme Court Approved Family Law Form 12.980(i), Motion for Extension of Injunction for Protection
Against Domestic, Repeat, Dating or Sexual Violence; or Stalking (03/15)
- 552 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.980(j)
MOTION FOR MODIFICATION OF INJUNCTION FOR PROTECTION
AGAINST DOMESTIC, REPEAT, DATING, OR SEXUAL VIOLENCE, OR
STALKING (03/15)

When should this form be used?

This form may be used if you are a party to a previously entered injunction for protection against
domestic, repeat, dating, or sexual violence, or stalking, and you want the court to modify the terms of
the injunction. If you use this form, you are called the moving party.

This form should be typed or printed in black ink. After completing this form, you should sign the form
before a notary public or the clerk of the circuit court. You should then file the original with the clerk in
the county where the original petition was filed and keep a copy for your records. You must file a
motion for modification before the previously entered order expires. If you have any questions or
need assistance completing this form, the clerk or family law intake staff will help you.

What should I do next?

For your case to proceed, you will need to set a hearing on your motion. You must properly notify the
other party of the motion and hearing. You should check with the clerk of court for information on the
local procedure for scheduling a hearing. When you know the date and time of your hearing, you should
file Notice of Hearing (General), Florida Supreme Court Approved Family Law Form 12.923, or other
appropriate notice of hearing form. You will need to serve a copy of your motion and Notice of Hearing
on the other party. Service of your motion must be in in a manner that is reasonably calculated to
apprise the other party of your motion and the hearing. Please note that if notice is mailed or e-mailed,
the court in certain circumstances may not consider mailing or e-mailing to be adequate notice. If you
want to be sure, you should consider using certified mail, return receipt requested, or having the motion
personally served. If you are not represented by an attorney in this action, you must file proof that
the other party personally received notice of your motion. This is a technical area of the law; if you
have any questions about it, you should consult a lawyer. For more information on personal service, see
the instructions for Summons: Personal Service on an Individual, Florida Family Law Rules of Procedure
Form 12.910(a).

You will need to appear at a hearing on your motion for modification of injunction. After the hearing, if
the judge grants your motion, he or she will prepare a new injunction for protection that contains the
modifications. After the judge signs the new injunction, the clerk will provide you with the necessary
copies. Make sure that you keep a certified copy of the new injunction with you at all times!

IMPORTANT INFORMATION REGARDING E-FILING

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Special notes...

If the injunction you are seeking to modify is for domestic violence and you want the court to modify

Instructions for Florida Supreme Court Approved Family Law Form 12.980(j), Motion for Modification of Injunction
for Protection Against Domestic, Repeat, Dating or Sexual Violence, or Stalking (03/15)
- 554 -
alimony, child support, or time-sharing of minor child(ren), you must establish that there has been a
change in circumstance(s), as required by chapter 61, Florida Statutes, or chapter 741, Florida Statutes,
as applicable, that requires this (these) modification(s). Be sure that you make these change(s) clear in
your motion.
With this form you may also file the following:
 Request for Confidential Filing of Address, Florida Supreme Court Approved Family Law
Form 12.980(h), if you fear that disclosing your address would put you in danger
because you are the victim of sexual battery, aggravated child abuse, stalking,
aggravated stalking, harassment, aggravated battery, or domestic violence, and you
wish to keep your address confidential.
 Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida
Supreme Court Approved Family Law Form 12.902(d), must be completed and attached
if the modification(s) you are seeking involves temporary custody of any minor
child(ren).
 Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or
(c), must be completed and attached if the modification(s) you are seeking involves
temporary alimony or temporary child support.
When completing this form, you should make sure that your reasons for requesting that the
injunction be modified are stated clearly and that you include all relevant facts.

Case No.:

Division:
_____________,
Petitioner,
and

_____________,
Respondent.

MOTION FOR MODIFICATION OF INJUNCTION FOR PROTECTION AGAINST
( ) DOMESTIC VIOLENCE ( ) REPEAT VIOLENCE
( ) DATING VIOLENCE ( ) SEXUAL VIOLENCE ( ) STALKING

I, {full legal name} , being sworn, certify that the following
statements are true:

SECTION I. MOVING PARTY
(This section is about you. It must be completed. However, if you fear that disclosing your address
would put you in danger because you are the victim of sexual battery, stalking, aggravated child
abuse, aggravated stalking, harassment, aggravated battery, or domestic violence, you should
complete and file a Request for Confidential Filing of Address, Florida Supreme Court Approved Family
Law Form 12.980(h), and write "confidential" in the space provided on this form for your address and
telephone number.)

1. Moving Party is the _____ Petitioner _____ Respondent in this case.

2. Moving Party currently lives at the following address: {street address}
{city, state, and zip code}
Telephone Number: {area code and number}

3. Moving Party's attorney's name, address and telephone number is:
.
(If you do not have an attorney, write "none.")

SECTION II. NEW INFORMATION

Florida Supreme Court Approved Family Law Form 12.980(j), Motion for Modification of Injunction for Protection
Against Domestic, Repeat, Dating or Sexual Violence, or Stalking (03/15)
- 556-
New information since the previous injunction was issued: (If known, write the other party's new
address, place of employment, physical description, vehicle, aliases or nicknames, or attorney’s name.)

SECTION III. CASE HISTORY AND REASON FOR SEEKING MODIFICATION OF INJUNCTION

2. Describe any other court cases (including case numbers, if known) since the date of the current
injunction between Petitioner and Respondent, including any cases involving the parties' minor
child(ren), divorce, juvenile dependency, guardianship, or other civil or criminal cases.

3. Moving Party requests that the previously entered injunction for protection against domestic
violence, repeat violence, dating violence, sexual violence, or stalking, be modified for the following
specific reasons: {State why you wish the injunction to be changed.}

.
_____Please indicate here if you are attaching additional pages to continue these facts.

Florida Supreme Court Approved Family Law Form 12.980(j), Motion for Modification of Injunction for Protection
Against Domestic, Repeat, Dating or Sexual Violence, or Stalking (03/15)
- 557-
SECTION IV. REQUESTED RELIEF
1. Moving Party understands that the Court will hold a hearing on this motion and that he or she
must appear at the hearing.

2. Moving Party asks the Court to enter an order in this case that modifies the previously entered
injunction in the following ways: {State how you wish the injunction to be changed.}

I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) mailed
by certified mail, return receipt requested, ( ) furnished to a law enforcement officer for personal
service to the person(s) listed below on {date} .

Other party or his/her attorney:
Name:
Address:
City, State, Zip:
Fax Number:
Designated E-Mail Address(es): ____________
_______________________________________

Dated: ____ ____________________________________________
Signature of Party
STATE OF FLORIDA
COUNTY OF

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

Florida Supreme Court Approved Family Law Form 12.980(j), Motion for Modification of Injunction for Protection
Against Domestic, Repeat, Dating or Sexual Violence, or Stalking (03/15)
- 558-
{Print, type, or stamp commissioned name of notary or clerk}
__ Personally known
__ Produced identification
Type of identification produced

Case No.:
Division:
,
Petitioner,
and

,
Respondent.

TEMPORARY INJUNCTION FOR PROTECTION AGAINST REPEAT VIOLENCE
The Petition for Injunction for Protection Against Repeat Violence under section 784.046, Florida
Statutes, and other papers filed in this Court have been reviewed. Under the laws of Florida, the Court
has jurisdiction of the petitioner and the subject matter and has jurisdiction of the respondent upon
service of the temporary injunction. The term Petitioner as used in this injunction includes the person
on whose behalf this injunction is entered.

SECTION I. NOTICE OF HEARING

Because this Temporary Injunction for Protection Against Repeat Violence has been issued without
notice to Respondent, the Petitioner and Respondent are instructed that they are scheduled to appear
and testify at a hearing regarding this matter on {date} ,
at a.m./p.m., when the Court will consider whether to issue a Final Judgment of
Injunction for Protection Against Repeat Violence, which shall remain in effect until modified or
dissolved by the Court, and whether other things should be ordered. The hearing will be before The
Honorable {name} , at {room name/number, location, address, city}
______________________________________________________________________________, Florida.
If Petitioner and/or Respondent do not appear, this temporary injunction may be continued in force,
extended, or dismissed, and/or additional orders may be granted, including entry of a permanent
injunction and the imposition of court costs. All witnesses and evidence, if any, must be presented at
this time. Petitioner and Respondent will be bound by the terms of any injunction or order issued at
the final hearing.

IF EITHER PETITIONER OR RESPONDENT DO NOT APPEAR AT THE FINAL HEARING, HE OR SHE WILL BE
BOUND BY THE TERMS OF ANY INJUNCTION OR ORDER ISSUED IN THIS MATTER.

Florida Supreme Court Approved Family Law Form 12.980(k), Temporary Injunction for Protection Against Repeat
Violence (03/15)
- 560 -
NOTICE: Because this is a civil case, there is no requirement that these proceedings be transcribed at
public expense.

YOU ARE ADVISED THAT IN THIS COURT:

a. ____ a court reporter is provided by the court.

b. ____ electronic recording only is provided by the court. A party may arrange in advance for the
services of and provide for a court reporter to prepare a written transcript of the proceedings at that
party’s expense.

c. ____ neither electronic recording nor court reporting services are provided by the court. A party may
arrange in advance for the services of and provide for a court reporter to prepare a written transcript of
the proceedings at that party’s expense.

The statements made under oath by Petitioner make it appear that Section 784.046, Florida Statutes,
applies to the parties, that Petitioner is a victim of repeat violence and that an immediate and present
danger of repeat violence exists to Petitioner or to a member of Petitioner's immediate family.

SECTION III. TEMPORARY INJUNCTION AND TERMS

Florida Supreme Court Approved Family Law Form 12.980(k), Temporary Injunction for Protection Against Repeat
Violence (03/15)
- 561 -
may not be changed by either party alone or by both parties together. Only the Court may modify the
terms of this injunction. Either party may ask the Court to change or end this injunction.
Willful violation of the terms of this injunction, such as refusing to vacate the dwelling which the
parties share, going to Petitioner's residence, place of employment, school, or other place prohibited
in this injunction, telephoning, contacting or communicating with Petitioner, if prohibited by this
injunction, or committing an act of repeat violence against Petitioner constitutes a misdemeanor of
the first degree punishable by up to one year in jail, as provided by Sections 775.082 and 775.083,
Florida Statutes.
Any party violating this injunction may be subject to civil or indirect criminal contempt proceedings,
including the imposition of a fine or imprisonment, and also may be charged with a crime punishable
by a fine, jail, or both, as provided by Florida Statutes.
ORDERED and ADJUDGED:
1. Violence Prohibited. Respondent shall not commit, or cause any other person to commit, any
acts of violence against Petitioner, including assault, aggravated assault, battery, aggravated battery,
sexual assault, sexual battery, stalking, aggravated stalking, kidnapping, or false imprisonment or any
criminal offense resulting in physical injury or death. Respondent shall not commit any other violation
of the injunction through an intentional unlawful threat, word, or act to do violence to the Petitioner.

[Initial if applies; write N/A if not applicable]
b. ____Respondent may not knowingly come within 100 feet of Petitioner’s automobile at
any time.
c. ____Other provisions regarding contact:
.

3. Firearms.

Florida Supreme Court Approved Family Law Form 12.980(k), Temporary Injunction for Protection Against Repeat
Violence (03/15)
- 562 -
[Initial all that apply; write N/A if does not apply]

Florida Supreme Court Approved Family Law Form 12.980(k), Temporary Injunction for Protection Against Repeat
Violence (03/15)
- 563 -
a. ____Respondent shall not use or possess a firearm or ammunition.

b. ____Respondent shall surrender any firearms and ammunition in Respondent's possession to
the _______ County Sheriff's Department.

c. ____Other directives relating to firearms and ammunition:

4. Mailing Address or Designated E-Mail Address(es). Respondent shall notify the Clerk of the
Court of any change in either his or her mailing address, or designated e-mail address(es), within 10 days
of the change. All further papers (excluding pleadings requiring personal service) shall be served either
by mail to Respondent’s last known mailing address or by e-mail to Respondent’s designated e-mail
address(es). Service by mail or e-mail shall be complete upon mailing.

5. Additional order(s) necessary to protect Petitioner from repeat violence:

SECTION IV. OTHER SPECIAL PROVISIONS
{This section to be used for inclusion of local provisions approved by the chief judge as provided in Florida
Family Law Rule 12.610.}
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________ .

1. The Sheriff of County, or any other authorized law enforcement officer, is
ordered to serve this temporary injunction upon Respondent as soon as possible after its issuance.

2. This injunction is valid and enforceable in all counties of the State of Florida. Violation of this
injunction should be reported to the appropriate law enforcement agency. Law enforcement officers of
the jurisdiction in which a violation of this injunction occurs shall enforce the provisions of this
injunction and are authorized to arrest without a warrant pursuant to Section 901.15, Florida Statutes,
for any violation of its provisions, which constitutes a criminal act under Section 784.047, Florida

Florida Supreme Court Approved Family Law Form 12.980(k), Temporary Injunction for Protection Against Repeat
Violence (03/15)
- 564 -
Statutes.

3. Should any Florida law enforcement officer having jurisdiction have probable cause to believe
that Respondent has knowingly violated this injunction, the officer may arrest Respondent, confine
him/her in the county jail without bail, and shall bring him/her before the Initial Appearance Judge on
the next regular court day so that Respondent can be dealt with according to law. The arresting agent
shall notify the State Attorney's Office immediately after arrest. THIS INJUNCTION IS ENFORCEABLE IN
ALL COUNTIES OF FLORIDA AND LAW ENFORCEMENT OFFICERS MAY EFFECT ARRESTS PURSUANT TO
SECTION 901.15(6), FLORIDA STATUTES.

4. Reporting alleged violations. If Respondent violates the terms of this injunction and there has
not been an arrest, Petitioner may contact the Clerk of the Circuit Court of the county in which the
violation occurred and complete an affidavit in support of the violation or Petitioner may contact the
State Attorney’s office for assistance in filing an action for indirect civil contempt or indirect criminal
contempt. Upon receiving such a report, the State Attorney is hereby appointed to prosecute such
violations by indirect criminal contempt proceedings, or the State Attorney may decide to file a criminal
charge, if warranted by the evidence.

DONE AND ORDERED in ____________________, Florida on ___________________.

______________________________________
CIRCUIT JUDGE

COPIES TO:

Sheriff of _____________________ County

Petitioner:
_____ by U.S. Mail
_____by hand delivery in open court
_____by e-mail to designated e-mail address(es)

Respondent:
_____ forwarded to the sheriff for service

_____State’s Attorney’s Office

_____Other:_____________________

Florida Supreme Court Approved Family Law Form 12.980(k), Temporary Injunction for Protection Against Repeat
Violence (03/15)
- 565 -
I CERTIFY the foregoing is a true copy of the original Temporary Injunction for Protection Against Repeat
Violence as it appears on file in the office of the Clerk of the Circuit Court of ___________________
County, Florida, and that I have furnished copies of this order as indicated above.

CLERK OF THE CIRCUIT COURT
(SEAL)
By:
{Deputy Clerk or Judicial Assistant}

Florida Supreme Court Approved Family Law Form 12.980(k), Temporary Injunction for Protection Against Repeat
Violence (03/15)
- 566 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
__________________,
Petitioner,
and

___________________,
Respondent.

FINAL JUDGMENT OF INJUNCTION FOR PROTECTION AGAINST
REPEAT VIOLENCE (AFTER NOTICE)

The Petition for Injunction for Protection Against Repeat Violence under Section 784.046, Florida
Statutes, and other papers filed in this Court have been reviewed. The Court has jurisdiction of the
parties and the subject matter. The term Petitioner as used in this injunction includes the person on
whose behalf this injunction is entered.

SECTION I. HEARING

This cause came before the Court for a hearing to determine whether an Injunction for Protection
Against Repeat Violence in this case should be:
____ issued ____ modified ____ extended.
The hearing was attended by:
_____ Petitioner
_____ Petitioner’s Counsel
_____ Respondent
_____ Respondent’s Counsel

SECTION II. FINDINGS

Florida Supreme Court Approved Family Law Form 12.980(l), Final Judgment of Injunction for Protection Against
Repeat Violence (After Notice) (03/15)
- 567 -
After hearing the testimony of each party present and of any witnesses, or upon consent of Respondent,
the Court finds, based on the specific facts of this case, that Petitioner is a victim of repeat violence.

SECTION III. INJUNCTION AND TERMS

This injunction shall be in full force and effect until either ____ further order of the Court or _____
{date} . This injunction is valid and enforceable throughout all counties in the State
of Florida. The terms of this injunction may not be changed by either party alone or by both parties
together. Only the Court may modify the terms of this injunction. Either party may ask the Court to
change or end this injunction.

Willful violation of the terms of this injunction, such as refusing to vacate the dwelling which the
parties share, going to Petitioner's residence, place of employment, school, or other place prohibited
in this injunction, telephoning, contacting or communicating with Petitioner, if prohibited by this
injunction, or committing an act of repeat violence against Petitioner constitutes a misdemeanor of
the first degree punishable by up to one year in jail, as provided by Sections 775.082 and 775.083,
Florida Statutes.

Any party violating this injunction shall be subject to civil or indirect criminal contempt proceedings,
including the imposition of a fine or imprisonment, and also may be charged with a crime punishable
by a fine, jail, or both, as provided by Florida Statutes.

ORDERED and ADJUDGED:

1. Violence Prohibited. Respondent shall not commit, or cause any other person to commit, any
acts of violence against Petitioner, including assault, aggravated assault, battery, aggravated battery,
sexual assault, sexual battery, stalking, aggravated stalking, kidnapping, or false imprisonment, or any
criminal offense resulting in physical injury or death. Respondent shall not commit any other violation
of the injunction through an intentional unlawful threat, word or act to do violence to the Petitioner.

2. No Contact. Respondent shall have no contact with Petitioner unless otherwise provided in
this section.

Florida Supreme Court Approved Family Law Form 12.980(l), Final Judgment of Injunction for Protection Against
Repeat Violence (After Notice) (03/15)
- 568 -
employment {list address of current employment}_____________________________________
or place where Petitioner attends school {list address of school}_________________________ ;
or the following other places (if requested by Petitioner) where Petitioner or Petitioner’s minor
child(ren) go often:________________________________________________________
_____________________________________________________________________________
______________________________________________________________________________ .

{Initial if applies; write N/A if not applicable}
b. _____Respondent may not knowingly come within 100 feet of Petitioner's automobile at any
time.

c. _____Other provisions regarding contact: ________________________________________
_____________________________________________________________________________
_____________________________________________________________________________.

3. Firearms.
{Initial all that apply; write N/A if not applicable}
a._____ Respondent shall not use or possess a firearm or ammunition.

b. _____Respondent shall surrender any firearms and ammunition in the Respondent's
possession to the __________________County Sheriff's Department.

c. _____Other directives relating to firearms and ammunition:

4. Mailing Address or Designated E-Mail Address(es). Respondent shall notify the Clerk of the
Court of any change in either his or her mailing address, or designated e-mail address(es), within 10 days
of the change. All further papers (excluding pleadings requiring personal service) shall be served by
either mail or e-mail to Respondent’s last known mailing address or by e-mail to Respondent’s
designated e-mail address(es). Service by mail or e-mail shall be complete upon mailing.

5. Additional order(s) necessary to protect Petitioner from repeat violence:

Florida Supreme Court Approved Family Law Form 12.980(l), Final Judgment of Injunction for Protection Against
Repeat Violence (After Notice) (03/15)
- 569 -
SECTION IV. OTHER SPECIAL PROVISIONS
{This section to be used for inclusion of local provisions approved by the chief judge as provided in Florida
Family Law Rule 12.610.}
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________.

1. This injunction is valid and enforceable in all counties of the State of Florida. Violation of this
injunction should be reported to the appropriate law enforcement agency. Law enforcement officers of
the jurisdiction in which a violation of this injunction occurs shall enforce the provisions of this
injunction and are authorized to arrest without a warrant pursuant to Section 901.15, Florida Statutes,
for any violation of its provision, which constitutes a criminal act under Section 784.047, Florida
Statutes.
2. Should any Florida law enforcement officer having jurisdiction have probable cause to believe
that Respondent has knowingly violated this injunction, the officer may arrest Respondent, confine
him/her in the county jail without bail, and shall bring him/her before the Initial Appearance Judge on
the next regular court day so that Respondent can be dealt with according to law. The arresting agent
shall notify the State Attorney's Office immediately after arrest. THIS INJUNCTION IS ENFORCEABLE IN
ALL COUNTIES OF FLORIDA AND LAW ENFORCEMENT OFFICERS MAY EFFECT ARRESTS PURSUANT TO
SECTION 901.15(6), FLORIDA STATUTES.
3. Reporting alleged violations. If Respondent violates the terms of this injunction and there has
not been an arrest, Petitioner may contact the Clerk of the Circuit Court of the county in which the
violation occurred and complete an affidavit in support of the violation or Petitioner may contact the
State Attorney’s office for assistance in filing an action for indirect civil contempt or indirect criminal
contempt. Upon receiving such a report, the State Attorney is hereby appointed to prosecute such
violations by indirect criminal contempt proceedings, or the State Attorney may decide to file a criminal
charge, if warranted by the evidence.
4. Respondent, upon service of this injunction, shall be deemed to have knowledge of and to be
bound by all matters occurring at the hearing and on the face of this injunction.
5. The temporary injunction, if any, entered in this case is extended until such time as service of
this injunction is effected upon Respondent.

DONE AND ORDERED in __________________________, Florida on _____________ .

Florida Supreme Court Approved Family Law Form 12.980(l), Final Judgment of Injunction for Protection Against
Repeat Violence (After Notice) (03/15)
- 570 -
CIRCUIT JUDGE
COPIES TO:
Sheriff of _________________________County

I CERTIFY the foregoing is a true copy of the original Final Judgment of Injunction for Protection Against
Repeat Violence as it appears on file in the office of the Clerk of the Circuit Court of _______________
County, Florida, and that I have furnished copies of this order as indicated above.

CLERK OF THE CIRCUIT COURT
(SEAL)
By:
{Deputy Clerk or Judicial Assistant}

Florida Supreme Court Approved Family Law Form 12.980(l), Final Judgment of Injunction for Protection Against
Repeat Violence (After Notice) (03/15)
- 571 -
ACKNOWLEDGMENT

I, {Name of Petitioner} , acknowledge receipt of a certified copy of
this Injunction for Protection.

_______________________________________
Petitioner

ACKNOWLEDGMENT

I, {Name of Respondent} , acknowledge receipt of a certified copy of
this Injunction for Protection.

________________________________________
Respondent

Florida Supreme Court Approved Family Law Form 12.980(l), Final Judgment of Injunction for Protection Against
Repeat Violence (After Notice) (03/15)
- 572 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR ___________ COUNTY, FLORIDA

Case No.:
Division:
__________________,
Petitioner
and

__________________,
Respondent.

ORDER EXTENDING INJUNCTION FOR PROTECTION AGAINST
( ) DOMESTIC VIOLENCE ( ) REPEAT VIOLENCE
( ) DATING VIOLENCE ( ) SEXUAL VIOLENCE ( ) STALKING

THIS CAUSE came before the Court on {date} , upon Petitioner’s motion for
an extension of injunction for protection and it appearing to the Court as follows:

1._____Ex parte.
The claims in the motion for extension of injunction for protection make it appear to the Court that
there is an immediate and present danger of domestic, repeat, dating, or sexual violence as required
under section 741.30 or section 784.046, Florida Statutes, or that stalking exists, pursuant to section
784.0485, Florida Statutes. The previously entered injunction is extended until {date} .
A full hearing on the petition is scheduled for {date} at _____ a.m./p.m. in
______________________________________________________________________________ .

NOTICE: Because this is a civil case, there is no requirement that these proceedings be transcribed at
public expense.

YOU ARE ADVISED THAT IN THIS COURT:

a. ____a court reporter is provided by the court.

b.____ electronic recording only is provided by the court. A party may arrange in advance for the
services of and provide for a court reporter to prepare a written transcript of the proceedings at that
party’s expense.

c. ____If this is a repeat violence, dating violence, or sexual violence action, no electronic recording or
court reporting services are provided by the court. A party may arrange in advance for the services of
and provide for a court reporter to prepare a written transcript of the proceedings at that party’s
expense.
Florida Supreme Court Approved Family Law Form 12.980(m), Order Extending Injunction for Protection Against
Domestic, Repeat, Dating or Sexual Violence, or Stalking (03/15)
- 573 -
A RECORD, WHICH INCLUDES A TRANSCRIPT, MAY BE REQUIRED TO SUPPORT AN APPEAL. THE PARTY
SEEKING THE APPEAL IS RESPONSIBLE FOR HAVING THE TRANSCRIPT PREPARED BY A COURT REPORTER.

THE TRANSCRIPT MUST BE FILED WITH THE REVIEWING COURT OR THE APPEAL MAY BE DENIED.

{identify applicable court personnel by name, address, and telephone number} at
least 7 days before your scheduled court appearance, or immediately upon
receiving this notification if the time before the scheduled appearance is less
than 7 days; if you are hearing or voice impaired, call 711.
2._____After notice and hearing.
Respondent was served with a copy of the temporary injunction, if applicable, and a notice of this
hearing within the time required by Florida law and was afforded an opportunity to be heard. The notice
and opportunity to be heard were sufficient to protect Respondent’s right to due process. The following
persons attended the hearing: ____ Petitioner ____ Respondent.

After hearing the testimony of each party present and of any witnesses, or upon consent of Respondent,
the Court finds that Petitioner is a victim of domestic, repeat , dating , or sexual violence, or stalking, or
reasonably fears that he/she will become a victim of domestic or dating violence from Respondent. The
previously entered injunction is extended until {date}________________________________________,
or until further order of the Court.

DONE AND ORDERED in __________________, Florida, on ______________________________.

________________________________
CIRCUIT JUDGE

Petitioner (or his or her attorney):
_____ by U.S. Mail
_____ by hand delivery in open court
(Petitioner must acknowledge receipt in writing on the face of the original order—see below)
_____ by e-mail to designated address

Respondent (or his or her attorney):
__ forwarded to sheriff for service
_____ by hand delivery in open court
(Respondent must acknowledge receipt in writing on the face of the original order—see below)
_____ by certified mail (may only be used when Respondent is present at the hearing and Respondent
fails or refuses to acknowledge the receipt of certified copy of this injunction)

__State Attorney’s Office

__Other:

I CERTIFY the foregoing is a true copy of the original Order Extending the Injunction for Protection as it
appears on file in the office of the Clerk of the Circuit Court of __________ County, Florida,
and that I have furnished copies of this order as indicated above.

CLERK OF THE CIRCUIT COURT

(SEAL)
By: _______________________________
Deputy Clerk or Judicial Assistant

Florida Supreme Court Approved Family Law Form 12.980(m), Order Extending Injunction for Protection Against
Domestic, Repeat, Dating or Sexual Violence, or Stalking (03/15)
- 575 -
ACKNOWLEDGMENT

I, {Name of Petitioner} , acknowledge receipt of a certified copy of this
Order Extending the Injunction for Protection.

________________________________________
Petitioner

ACKNOWLEDGMENT

I, {Name of Respondent} , acknowledge receipt of a certified copy of this
Order Extending the Injunction for Protection.

_______________________________________
Respondent

Florida Supreme Court Approved Family Law Form 12.980(m), Order Extending Injunction for Protection Against
Domestic, Repeat, Dating or Sexual Violence, or Stalking (03/15)
- 576 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.980(n)
PETITION FOR INJUNCTION FOR
PROTECTION AGAINST DATING VIOLENCE (03/15)

When should this form be used?

If you or a member of your immediate family are a victim of dating violence, you can use this form to
ask the court for a protective order prohibiting dating violence. Dating violence means violence between
individuals who have or have had a continuing and significant relationship of a romantic or intimate
nature. The dating relationship must have existed within the past six months, the nature of the
relationship must have been characterized by the expectation of affection or sexual involvement
between the parties, and the frequency and type of interaction must have included that the persons
have been involved over time and on a continuous basis during the course of the relationship. Dating
violence does not include violence in a casual acquaintanceship or violence between individuals who
only have engaged in ordinary fraternization in a business or social context.

Dating violence includes assault, aggravated assault, battery, aggravated battery, sexual assault, sexual
battery, stalking, aggravated stalking, kidnapping, or false imprisonment, or any criminal offense
resulting in physical injury or death. Because you are making a request to the court, you are called the
petitioner. The person whom you are asking the court to protect you from is called the respondent. If
you are under the age of eighteen and have never been married or had the disabilities of nonage
removed by a court, one of your parents or your legal guardian must sign this petition on your behalf.

The parent or legal guardian of any minor child who is living at home may seek an injunction for
protection against dating violence on behalf of the minor child. With respect to a minor child who is
living at home, the parent or legal guardian must have been an eye-witness to, or have direct physical
evidence or affidavits from eye-witnesses of, the specific facts and circumstances that form the basis of
the petition.

This form should be typed or printed in black ink. You should complete this form (giving as much detail
as possible) and sign it the presence of a notary or in front of the clerk of the circuit court in the county
where you live. The clerk will take your completed petition to a judge. You should keep a copy for your
records. If you have any questions or need assistance completing this form, the clerk or family law
intake staff will help you.

Instructions for Florida Supreme Court Approved Family Law Form 12.980(n), Petition for Injunction for Protection
Against Dating Violence (03/15)
- 577 -
What should I do if the judge grants my petition?

If the facts contained in your petition convince the judge that you or a member of your immediate
family are a victim of dating violence and that an immediate and present danger of dating violence to
you or that family exists, the judge will sign a Temporary Injunction for Protection Against Dating
Violence, Florida Supreme Court Approved Family Law Form 12.980(o). A temporary injunction is issued
without notice to the respondent. The clerk will give your petition, the temporary injunction, and any
other papers filed with your petition to the sheriff or other law enforcement officer for personal service
on the respondent. The temporary injunction will take effect immediately after the respondent is served
with a copy of it. It lasts until a full hearing can be held or for a period of 15 days, whichever comes first.
The court may extend the temporary injunction beyond 15 days for a good reason, which may include
failure to obtain service on the respondent.

The temporary injunction is issued ex parte. This means that the judge has considered only the
information presented by one side--YOU. Section I of the temporary injunction gives a date that you
should appear in court for a hearing. You will be expected to testify about the facts in your petition. The
respondent will be given the opportunity to testify at this hearing, also. At the hearing, the judge will
decide whether to issue a Final Judgment of Injunction for Protection Against Dating Violence (After
Notice), Florida Supreme Court Approved Family Law Form 12.980(p), which will remain in effect for a
specific time period or until modified or dissolved by the court. If you and/or the respondent do not
appear, the temporary injunction may be continued in force, extended, or dismissed, and/or
additional orders may be granted, including entry of a permanent injunction and the imposition of
court costs. You and respondent will be bound by the terms of any injunction or order issued at the
final hearing.

IF EITHER YOU OR RESPONDENT DO NOT APPEAR AT THE FINAL HEARING, YOU WILL BOTH BE BOUND
BY THE TERMS OF ANY INJUNCTION OR ORDER ISSUED IN THIS MATTER.

If the judge signs a temporary or final injunction, the clerk will provide you with the necessary copies.
Make sure that you keep one certified copy of the injunction with you at all times!

What can I do if the judge denies my petition?

If your petition is denied on the grounds that it appears to the court that no immediate and present
danger of dating violence exists, the court will set a full hearing on your petition. The respondent will be
notified by personal service of your petition and the hearing. If your petition is denied, you may: amend
your petition by filing a Supplemental Affidavit in Support of Petition for Injunction for Protection,
Florida Supreme Court Approved Family Law Form 12.980(g); attend the hearing and present facts that
support your petition; and/or dismiss your petition.

Instructions for Florida Supreme Court Approved Family Law Form 12.980(n), Petition for Injunction for Protection
Against Dating Violence (03/15)
- 578 -
Where can I look for more information?

IMPORTANT INFORMATION REGARDING E-FILING

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions for Florida Supreme Court Approved Family Law Form 12.980(n), Petition for Injunction for Protection
Against Dating Violence (03/15)
- 579 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR ___________ COUNTY, FLORIDA

Case No.:
Division:
___________________,
Petitioner,
and

___________________,
Respondent.

PETITION FOR INJUNCTION FOR PROTECTION AGAINST DATING
VIOLENCE
I, {full legal name} , being sworn, certify that the
following statements are true:

SECTION I. PETITIONER
(This section is about you. It must be completed.)

1. Petitioner currently lives at the following address: {address, city, state, zip code}_____________

Date of Birth of Petitioner: ___________________________.

[Indicate if applicable]
_____ Petitioner seeks an injunction for protection on behalf of a minor child. Petitioner is the
parent or legal guardian of {full legal name} __________________ ,
a minor child who is living at home.

2. Petitioner's attorney's name, address, and telephone number is: _________________________
.
(If you do not have an attorney, write "none.")

SECTION II. RESPONDENT
(This section is about the person you want to be protected from. It must be completed.)

1. Respondent currently lives at the following address: {address, city, state, and zip code}________

Respondent’s Driver’s License number is: {if known} _______________________________

2. Petitioner has known Respondent since {date}_____________________________________

Florida Supreme Court Approved Family Law Form 12.980(n), Petition for Injunction for Protection Against Dating
Violence (03/15)
- 580 -
3. Respondent's last known place of employment:_____________________________________
Employment address:_________________________________________________________
Working hours: ___________________________

4. Physical description of Respondent:
Race: ______ Sex: Male _____ Female _____ Date of Birth:____________
Height: _____ Weight: _____ Eye Color: _____ Hair Color:______________
Distinguishing marks and/or scars:
Vehicle: (make/model) _______________ Color: __________ Tag Number: ____________

5. Other names Respondent goes by (aliases or nicknames):_____________________________

6. Respondent's attorney’s name, address, and telephone number is: ____________________

(If you do not know whether Respondent has an attorney, write "unknown." If Respondent does not
have an attorney, write "none.")

7. If Respondent is a minor, the address of Respondent’s parent or legal guardian is:

SECTION III. CASE HISTORY AND REASON FOR SEEKING PETITION (This section must be completed.)

1. Describe the nature of the relationship between the Petitioner and Respondent (include the
length of time of the relationship, the romantic or intimate nature of the relationship, the frequency or
type of interaction, and any other facts that characterize the relationship)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
__________________________________________________.
_____Please indicate here if you are attaching additional pages to continue these facts.

2. Have the Petitioner and Respondent been involved in a dating relationship within the past six
months? ______ Yes No

3. Has Petitioner ever received or tried to get an injunction for protection against domestic
violence, dating violence, repeat violence, or sexual violence against Respondent in this or any other
court?

_____ Yes _____ No If yes, what happened in that case? {Include case number, if known}

Florida Supreme Court Approved Family Law Form 12.980(n), Petition for Injunction for Protection Against Dating
Violence (03/15)
- 581 -
4. Has Respondent ever received or tried to get an injunction for protection against domestic
violence, dating violence, repeat violence, or sexual violence against Petitioner in this or any other
court?
_____ Yes _____No If yes, what happened in that case? {Include case number, if known}

5. Describe any other court case that is either going on now or that happened in the past between
Petitioner and Respondent {include case number, if known}:

6. Respondent has directed an incident of violence, meaning assault, aggravated assault, battery,
aggravated battery, sexual assault, sexual battery, stalking, aggravated stalking, kidnapping, or false
imprisonment, or any criminal offense resulting in physical injury or death against Petitioner or a
member of Petitioner’s immediate family. The incident (including date and location) is described below.
On {date} , at {location} ___________________________ ,
Respondent ______________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________ .
_____Please indicate here if you are attaching additional pages to continue these facts.

7. Other prior incidents (including dates and location) are described below:
On {date} , at {location} _____________________________ ,
Respondent________________________________________________________________
___________________________________________________________________________
______________________________________________________________________________

.
_____Please indicate here if you are attaching additional pages to continue these facts.

8. Petitioner genuinely fears dating violence by Respondent. {Explain}:____________________
____________________________________________________________________________
_____________________________________________________________________________
______________________________________________________________________________

Florida Supreme Court Approved Family Law Form 12.980(n), Petition for Injunction for Protection Against Dating
Violence (03/15)
- 582 -
.

9. Additional Information
{Indicate all that apply}
a.____ Respondent owns, has, and/or is known to have guns or other weapons.
Describe weapon(s):__________________________________________________________
__________________________________________________________________________ .

b.____ This or prior acts of dating violence have been previously reported to: {person or agency}
_______________________________________________________________________
_______________________________________________________________________ .

SECTION IV. INJUNCTION
(This section must be completed.)

1. Petitioner asks the Court to enter a TEMPORARY INJUNCTION for protection against dating
violence that will be in place from now until the scheduled hearing in this matter.

2. Petitioner asks the Court to enter an injunction prohibiting Respondent from committing any
acts of violence against Petitioner and:

a. prohibiting Respondent from going to or within 500 feet of any place Petitioner lives;

b. prohibiting Respondent from going to or within 500 feet of Petitioner’s place(s) of employment or the
school that Petitioner attends; the address of Petitioner's place(s) of employment and/or school
is:______________________________________________________
;

c. prohibiting Respondent from contacting Petitioner by telephone, mail, by e-mail, in writing, through
another person, or in any other manner;

d. ordering Respondent not to use or possess any guns or firearms;

{Choose all that apply}
e. ____prohibiting Respondent from going to or within 500 feet of the following place(s) Petitioner or Petitioner’s imme

;

f. ____ prohibiting Respondent from knowingly and intentionally going to or within 100 feet of
Petitioner’s motor vehicle;
and any other terms the Court deems necessary for the safety of Petitioner and Petitioner’s
immediate family.

Florida Supreme Court Approved Family Law Form 12.980(n), Petition for Injunction for Protection Against Dating
Violence (03/15)
- 583 -
I UNDERSTAND THAT BY FILING THIS PETITION, I AM ASKING THE COURT TO HOLD A HEARING ON
THIS PETITION, THAT BOTH THE RESPONDENT AND I WILL BE NOTIFIED OF THE HEARING, AND THAT I
MUST APPEAR AT THE HEARING. I UNDERSTAND THAT IF EITHER RESPONDENT OR I FAIL TO APPEAR
AT THE FINAL HEARING, WE WILL BE BOUND BY THE TERMS OF ANY INJUNCTION OR ORDER ISSUED
AT THAT HEARING.

Dated: ____________________________ _______________________________________
Signature of Petitioner
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-Mail Address(es):______________
STATE OF FLORIDA _______________________________________
COUNTY OF

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

{Print, type, or stamp commissioned name of notary or clerk.}
__ Personally known
__ Produced identification
Type of identification produced

Florida Supreme Court Approved Family Law Form 12.980(n), Petition for Injunction for Protection Against Dating
Violence (03/15)
- 584 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR ____________ COUNTY, FLORIDA

Case No.:
Division:
__________________,
Petitioner,
and

___________________,
Respondent.

TEMPORARY INJUNCTION FOR PROTECTION AGAINST DATING VIOLENCE
The Petition for Injunction for Protection Against Dating Violence under Section 784.046, Florida
Statutes, and other papers filed in this Court have been reviewed. Under the laws of Florida, the Court
has jurisdiction of the petitioner and the subject matter and has jurisdiction of the respondent upon
service of the temporary injunction. The term Petitioner as used in this injunction includes the person
on whose behalf this injunction is entered.

SECTION I. NOTICE OF HEARING

Because this Temporary Injunction for Protection Against Dating Violence has been issued without
notice to Respondent, the Petitioner and Respondent are instructed that they are scheduled to appear
and testify at a hearing regarding this matter on {date} _______________________________, at
________ a.m./p.m., when the Court will consider whether to issue a Final Judgment of Injunction for
Protection Against Dating Violence, which shall remain in effect until modified or dissolved by the Court,
and whether other things should be ordered. The hearing will be before The Honorable {name}
__________________________, at {room name/number, location, address, city}
____________________________________________________ _________________________, Florida.
If Petitioner and/or Respondent do not appear, this temporary injunction may be continued in force,
extended, or dismissed, and/or additional orders may be granted, including entry of a permanent
injunction and the imposition of court costs. All witnesses and evidence, if any, must be presented at
this time. Petitioner and Respondent will be bound by the terms of any injunction or order issued at
the final hearing.

IF EITHER PETITIONER OR RESPONDENT DO NOT APPEAR AT THE FINAL HEARING, HE OR SHE WILL BE

Florida Supreme Court Approved Family Law Form 12.980(o), Temporary Injunction for Protection Against Dating
Violence (03/15)
- 585 -
BOUND BY THE TERMS OF ANY INJUNCTION OR ORDER ISSUED IN THIS MATTER.
NOTICE: Because this is a civil case, there is no requirement that these proceedings be transcribed at
public expense.

YOU ARE ADVISED THAT IN THIS COURT:

a._____ a court reporter is provided by the court.

b._____electronic recording only is provided by the court. A party may arrange in advance for the
services of and provide for a court reporter to prepare a written transcript of the proceedings at that
party’s expense.

c._____ neither electronic recording nor court reporting services are provided by the court. A party may
arrange in advance for the services of and provide for a court reporter to prepare a written transcript of
the proceedings at that party’s expense.

The statements made under oath by Petitioner make it appear that Section 784.046, Florida Statutes,
applies to the parties, that Petitioner is a victim of dating violence and/or Petitioner has reasonable
cause to believe he or she is in imminent danger of becoming a victim of an act of dating violence by
Respondent, and that an immediate and present danger of dating violence exists to Petitioner or to a
member of Petitioner's immediate family.

SECTION III. TEMPORARY INJUNCTION AND TERMS

This injunction shall be effective until the hearing set above and in no event for longer than 15 days,

Florida Supreme Court Approved Family Law Form 12.980(o), Temporary Injunction for Protection Against Dating
Violence (03/15)
- 586 -
unless extended by court order. If a final order of injunction is issued, the terms of this temporary
injunction will be extended until service of the final injunction is effected upon Respondent. This
injunction is valid and enforceable in all counties of the State of Florida. The terms of this injunction
may not be changed by either party alone or by both parties together. Only the Court may modify the
terms of this injunction. Either party may ask the Court to change or end this injunction.
Willful violation of the terms of this injunction, such as refusing to vacate the dwelling which the
parties share, going to Petitioner's residence, place of employment, school, or other place prohibited
in this injunction, telephoning, contacting or communicating with Petitioner, if prohibited by this
injunction, or committing an act of dating violence against Petitioner constitutes a misdemeanor of
the first degree punishable by up to one year in jail, as provided by Sections 775.082 and 775.083,
Florida Statutes.
Any party violating this injunction may be subject to civil or indirect criminal contempt proceedings,
including the imposition of a fine or imprisonment, and also may be charged with a crime punishable
by a fine, jail, or both, as provided by Florida Statutes.
ORDERED and ADJUDGED:
1. Violence Prohibited. Respondent shall not commit, or cause any other person to commit, any
acts of violence against Petitioner, including assault, aggravated assault, battery, aggravated battery,
sexual assault, sexual battery, stalking, aggravated stalking, kidnapping, or false imprisonment, or any
criminal offense resulting in physical injury or death. Respondent shall not commit any other violation
of the injunction through an intentional unlawful threat, word, or act to do violence to the Petitioner.

2. No Contact. Respondent shall have no contact with the Petitioner unless otherwise provided
in this section.
a. Unless otherwise provided herein, Respondent shall have no contact with Petitioner. Respondent
shall not directly or indirectly contact Petitioner in person, by mail, e-mail, fax, telephone, through
another person, or in any other manner. Further, Respondent shall not contact or have any third party
contact anyone connected with Petitioner's employment or school to inquire about Petitioner or to send
any messages to Petitioner. Unless otherwise provided herein, Respondent shall not go to, in, or within
500 feet of: Petitioner’s current residence {list address}
________________________________________________________________________
or any residence to which Petitioner may move; Petitioner’s current or any subsequent place of
employment {list address of current employment}
________________________________ or place where Petitioner attends school {list address of school} ;
or the following other places (if requested by Petitioner) where Petitioner or Petitioner’s minor
child(ren) go often:
______________________________________________________________________________
______________________________________________________________________________

______________________________________________________________________________
______________________________________________________________________________

Florida Supreme Court Approved Family Law Form 12.980(o), Temporary Injunction for Protection Against Dating
Violence (03/15)
- 587 -
{Initial if applies; write N/A if not applicable}
b. ____Respondent may not knowingly come within 100 feet of Petitioner’s automobile at any
time.
c. ____Other provisions regarding contact:________________________________________
____________________________________________________________________________
____________________________________________________________________________

3. Firearms.
[Initial all that apply; write N/A if does not apply]
a. ____Respondent shall not use or possess a firearm or ammunition.
b. ____Respondent shall surrender any firearms and ammunition in Respondent's possession to
the County Sheriff's Department.
c. ____Other directives relating to firearms and ammunition:___________________________
____________________________________________________________________________
____________________________________________________________________________

4. Mailing Address or Designated E-Mail Address(es). Respondent shall notify the Clerk of the
Court of any change in either his or her mailing address, or designated e-mail address(es), within 10 days
of the change. All further papers (excluding pleadings requiring personal service) shall be served either
by mail to Respondent’s last known mailing address or by e-mail to Respondent’s designated e-mail
address(es). Service shall be complete upon mailing or e-mailing.

5. Additional order(s) necessary to protect Petitioner from dating violence:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________ .

SECTION IV. OTHER SPECIAL PROVISIONS
{This section to be used for inclusion of local provisions approved by the chief judge as provided in Florida
Family Law Rule 12.610.}
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

1. The Sheriff of ______________ County, or any other authorized law enforcement officer, is
ordered to serve this temporary injunction upon Respondent as soon as possible after its
issuance.

Florida Supreme Court Approved Family Law Form 12.980(o), Temporary Injunction for Protection Against Dating
Violence (03/15)
- 588 -
2. This injunction is valid and enforceable in all counties of the State of Florida. Violation of this
injunction should be reported to the appropriate law enforcement agency. Law enforcement officers of
the jurisdiction in which a violation of this injunction occurs shall enforce the provisions of this
injunction and are authorized to arrest without a warrant pursuant to Section 901.15, Florida Statutes,
for any violation of its provisions, which constitutes a criminal act under Section 784.047, Florida
Statutes.

4. Reporting alleged violations. If Respondent violates the terms of this injunction and there has
not been an arrest, Petitioner may contact the Clerk of the Circuit Court of the county in which the
violation occurred and complete an affidavit in support of the violation or Petitioner may contact the
State Attorney’s office for assistance in filing an action for indirect civil contempt or indirect criminal
contempt. Upon receiving such a report, the State Attorney is hereby appointed to prosecute such
violations by indirect criminal contempt proceedings, or the State Attorney may decide to file a criminal
charge, if warranted by the evidence.

DONE AND ORDERED in ___________________________, Florida on .

_______________________________________
CIRCUIT JUDGE

COPIES TO:
Sheriff of ________ County

Petitioner:

Florida Supreme Court Approved Family Law Form 12.980(o), Temporary Injunction for Protection Against Dating
Violence (03/15)
- 589 -
__ by U. S. Mail
__ by hand delivery in open court
_____ by e-mail to designated e-mail address(es)

Respondent:
__ forwarded to sheriff for service

____ State Attorney’s Office
__ Other: ________________________

I CERTIFY the foregoing is a true copy of the original Temporary Injunction for Protection Against Dating
Violence as it appears on file in the office of the Clerk of the Circuit Court of County,
Florida, and that I have furnished copies of this order as indicated above.

CLERK OF THE CIRCUIT COURT
(SEAL)

By:_______________________________________
{Deputy Clerk or Judicial Assistant}

Florida Supreme Court Approved Family Law Form 12.980(o), Temporary Injunction for Protection Against Dating
Violence (03/15)
- 590 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR __________ COUNTY, FLORIDA

Case No.:
Division:
___________________,
Petitioner,
and

___________________ ,
Respondent.

FINAL JUDGMENT OF INJUNCTION FOR PROTECTION AGAINST
DATING VIOLENCE (AFTER NOTICE)

The Petition for Injunction for Protection Against Dating Violence under Section 784.046, Florida
Statutes, and other papers filed in this Court have been reviewed. The Court has jurisdiction of the
parties and the subject matter. The term Petitioner as used in this injunction includes the person on
whose behalf this injunction is entered.

SECTION I. HEARING

This cause came before the Court for a hearing to determine whether an Injunction for Protection
Against Dating Violence in this case should be:
____ issued ____ modified ____ extended.
The hearing was attended by:
____ Petitioner
____Petitioner’s Counsel
____Respondent
____Respondent’s Counsel

SECTION II. FINDINGS

On {date} _____________________, a notice of this hearing was served on Respondent together with a
copy of Petitioner’s petition to this Court and the temporary injunction, if issued. Service was within the
time required by Florida law, and Respondent was afforded an opportunity to be heard.

Florida Supreme Court Approved Family Law Form 12.980(p), Final Judgment of Injunction for Protection Against
Dating Violence (After Notice) (03/15)
- 591 -
After hearing the testimony of each party present and of any witnesses, or upon consent of Respondent,
the Court finds, based on the specific facts of this case, that Petitioner is a victim of dating violence
and/or Petitioner has reasonable cause to believe he or she is in imminent danger of becoming a victim
of an act of dating violence by Respondent, and that an immediate and present danger of dating
violence exists to Petitioner or to a member of Petitioner's immediate family.

SECTION III. INJUNCTION AND TERMS

This injunction shall be in full force and effect until ____ further order of the Court or ____ {date}
__________________________. This injunction is valid and enforceable throughout all counties in the
State of Florida. The terms of this injunction may not be changed by either party alone or by both
parties together. Only the Court may modify the terms of this injunction. Either party may ask the
Court to change or end this injunction.

Willful violation of the terms of this injunction, such as refusing to vacate the dwelling which the
parties share, going to Petitioner's residence, place of employment, school, or other place prohibited
in this injunction, telephoning, contacting or communicating with Petitioner, if prohibited by this
injunction, or committing an act of dating violence against Petitioner constitutes a misdemeanor of
the first degree punishable by up to one year in jail, as provided by Sections 775.082 and 775.083,
Florida Statutes.

ORDERED and ADJUDGED:

Florida Supreme Court Approved Family Law Form 12.980(p), Final Judgment of Injunction for Protection Against
Dating Violence (After Notice) (03/15)
- 592 -
___________________________________________________________
or any residence
to which Petitioner may move; Petitioner’s current or any subsequent place of employment {list address
of current employment}___
or place where Petitioner attends school {list address of school} _________________________
_______________________________________; or the following other places (if requested by
Petitioner) where Petitioner or Petitioner’s minor child(ren) go often: ___________________
_____________________________________________________________________________
_____________________________________________________________________________

{Initial if applies; write N/A if not applicable}
b.____ Respondent may not knowingly come within 100 feet of Petitioner's automobile at any time.
c. ____Other provisions regarding contact:

3. Firearms.
{Initial all that apply; write N/A if does not apply}
a.____Respondent shall not use or possess a firearm or ammunition.

b.____Respondent shall surrender any firearms and ammunition in the Respondent's possession to
the___________________ County Sheriff's Department.

c. ____Other directives relating to firearms and ammunition:___________________________
_____________________________________________________________________________ .

4. Mailing Address or Designated E-Mail Address(es). Respondent shall notify the Clerk of the
Court of any change in either his or her mailing address, or designated e-mail address(es), within 10 days
of the change. All further papers (excluding pleadings requiring personal service) shall be served either
by mail to Respondent’s last known mailing address or by e-mail to Respondent’s designated e-mail
address(es). Service shall be complete upon mailing or e-mailing.

5. Additional order(s) necessary to protect Petitioner from dating violence: ______________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________ .

Florida Supreme Court Approved Family Law Form 12.980(p), Final Judgment of Injunction for Protection Against
Dating Violence (After Notice) (03/15)
- 593 -
SECTION IV. OTHER SPECIAL PROVISIONS
{This section to be used for inclusion of local provisions approved by the chief judge as provided in Florida
Family Law Rule 12.610.}

DONE AND ORDERED in____________________________, Florida on _____________________.

__________________________________________
CIRCUIT JUDGE

Florida Supreme Court Approved Family Law Form 12.980(p), Final Judgment of Injunction for Protection Against
Dating Violence (After Notice) (03/15)
- 594 -
COPIES TO:
Sheriff of County

____ State Attorney’s Office
____ Other _____________________________________________

I CERTIFY the foregoing is a true copy of the original Final Judgment of Injunction for Protection Against
Dating Violence as it appears on file in the office of the Clerk of the Circuit Court of _______
County, Florida, and that I have furnished copies of this order as indicated above.

CLERK OF THE CIRCUIT COURT
(SEAL)

By:_______________________________________
Deputy Clerk or Judicial Assistant

ACKNOWLEDGMENT

I, {Name of Petitioner} ___________________________, acknowledge receipt of a certified copy of this
Injunction for Protection.

Florida Supreme Court Approved Family Law Form 12.980(p), Final Judgment of Injunction for Protection Against
Dating Violence (After Notice) (03/15)
- 595 -
Petitioner

ACKNOWLEDGMENT

I, {Name of Respondent} ________________________________, acknowledge receipt of a certified copy
of this Injunction for Protection.

Respondent

Florida Supreme Court Approved Family Law Form 12.980(p), Final Judgment of Injunction for Protection Against
Dating Violence (After Notice) (03/15)
- 596 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.980(q)
PETITION FOR INJUNCTION FOR
PROTECTION AGAINST SEXUAL VIOLENCE (03/15)

When should this form be used?

If you are a victim of sexual violence or the parent or legal guardian of a minor child who is living at
home and is a victim of sexual violence, you can use this form to ask the court for a protective order
prohibiting sexual violence. Sexual violence means any one incident of:
 sexual battery, as defined in Chapter 794, Florida Statutes;
 a lewd or lascivious act, as defined in Chapter 800, Florida Statutes, committed upon or in the
presence of a person younger than 16 years of age;
 luring or enticing a child, as described in Chapter 787, Florida Statutes;
 sexual performance by a child, as described in Chapter 827, Florida Statutes; or
 any other forcible felony wherein a sexual act is committed or attempted

In order to get an injunction you must have reported the sexual violence to a law enforcement agency
and be cooperating in the criminal proceeding if there is one. It does not matter whether criminal
charges based on the sexual violence have been filed, reduced, or dismissed by the state attorney’s
office. You may also seek an injunction for protection against sexual violence if the respondent was sent
to prison for committing one of the sexual violence crimes listed above against you or your minor child
living at home and respondent is out of prison or is getting out of prison within 90 days of your petition.
Attach the notice of inmate release to your petition.

Because you are making a request to the court, you are called the petitioner. The person whom you are
asking the court to protect you from is called the respondent. If you are seeking an injunction for
protection against sexual violence on behalf of a minor child who is living at home, the parent or legal
guardian must have been an eyewitness to, or have direct physical evidence or affidavits from
eyewitnesses of, the specific facts and circumstances that form the basis of the petition. If you are under
the age of eighteen and have never been married or had the disabilities of nonage removed by a court,
one of your parents or your legal guardian must sign this petition on your behalf.

If the respondent is your spouse, former spouse, related to you by blood or marriage, living with you
now or has lived with you in the past (if you are or were living as a family), or is the other parent of your
child(ren) whether or not you have ever been married or ever lived together, you should use Petition for
Injunction for Protection Against Domestic Violence, Florida Supreme Court Approved Family Law Form
12.980(a), rather than this form.

Instructions for Florida Supreme Court Approved Family Law Form 12.980(q), Petition for Injunction for Protection
Against Sexual Violence (03/15)
- 597 -
where you live. The clerk will take your completed petition to a judge. You should keep a copy for your
records. If you have any questions or need assistance completing this form, the clerk or family law
intake staff will help you.

What should I do if the judge grants my petition?

If the facts contained in your petition convince the judge that an immediate and present danger of
violence exists, the judge will sign a Temporary Injunction for Protection Against Sexual Violence,
Florida Supreme Court Approved Family Law Form 12.980(r). A temporary injunction is issued without
notice to the respondent. The clerk will give your petition, the temporary injunction, and any other
papers filed with your petition to the sheriff or other law enforcement officer for personal service on
the respondent. The temporary injunction will take effect immediately after the respondent is served
with a copy of it. It lasts until a full hearing can be held or for a period of 15 days, whichever comes first,
unless the respondent is incarcerated, and in such instance the temporary injunction is effective for 15
days following the date the respondent is released from incarceration. The court may extend the
temporary injunction beyond 15 days for a good reason, which may include failure to obtain service on
the respondent.

The temporary injunction is issued ex parte. This means that the judge has considered only the
information presented by one side--YOU. Section I of the temporary injunction gives a date that you
should appear in court for a hearing. You will be expected to testify about the facts in your petition. The
respondent will be given the opportunity to testify at this hearing, also. At the hearing, the judge will
decide whether to issue a Final Judgment of Injunction for Protection Against Sexual Violence (After
Notice), Florida Supreme Court Approved Family Law Form 12.980(s), which will remain in effect for a
specific time period or until modified or dissolved by the court. If you and/or the respondent do not
appear, the temporary injunction may be continued in force, extended, or dismissed, and/or
additional orders may be granted, including entry of a permanent injunction and the imposition of
court costs. You and respondent will be bound by the terms of any injunction or order issued at the
final hearing.

IF EITHER YOU OR RESPONDENT DO NOT APPEAR AT THE FINAL HEARING, YOU WILL BOTH BE BOUND
BY THE TERMS OF ANY INJUNCTION OR ORDER ISSUED IN THIS MATTER.

If the judge signs a temporary or final injunction, the clerk will provide you with the necessary copies.
Make sure that you keep one certified copy of the injunction with you at all times!

What can I do if the judge denies my petition?

If your petition is denied on the grounds that it appears to the court that no immediate and present
danger of sexual violence exists, the court will set a full hearing on your petition. The respondent will be
notified by personal service of your petition and the hearing. If your petition is denied, you may: amend

Instructions for Florida Supreme Court Approved Family Law Form 12.980(q), Petition for Injunction for Protection
Against Sexual Violence (03/15)
- 598 -
your petition by filing a Supplemental Affidavit in Support of Petition for Injunction for Protection,
Florida Supreme Court Approved Family Law Form 12.980 (g); attend the hearing and present facts that
support your petition; and/or dismiss your petition.

Where can I look for more information?

IMPORTANT INFORMATION REGARDING E-FILING

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Special Notes . . .

Instructions for Florida Supreme Court Approved Family Law Form 12.980(q), Petition for Injunction for Protection
Against Sexual Violence (03/15)
- 599 -
If you fear that disclosing your address would put you in danger, you should complete a Request for
Confidential Filing of Address, Florida Supreme Court Approved Family Law Form 12.980(h), and file it
with the clerk of the circuit court and write confidential in the space provided for your address on the
petition.

Instructions for Florida Supreme Court Approved Family Law Form 12.980(q), Petition for Injunction for Protection
Against Sexual Violence (03/15)
- 600 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR _______________ COUNTY, FLORIDA

Case No.:
Division:
____________________,
Petitioner,
and

____________________,
Respondent.

PETITION FOR INJUNCTION FOR PROTECTION AGAINST SEXUAL VIOLENCE

I, {full legal name} ____________________________________ being sworn, certify that the following
statements are true:

SECTION I. PETITIONER
(This section is about you. It must be completed; however, if you fear that disclosing your address to
the respondent would put you in danger, you should complete and file a Request for Confidential Filing
of Address, Florida Supreme Court Approved Family Law Form 12.980(h), and write confidential in the
space provided on this form for your address.)

1. Petitioner currently lives at the following address: {address, city, state, zip code} ______

Date of Birth of Petitioner:

{Indicate if applicable}
_____ Petitioner seeks an injunction for protection on behalf of a minor child.
Petitioner is the parent or legal guardian of {full legal name}_________________ ,
a minor child who is living at home.

2. Petitioner's attorney's name, address, and telephone number is:_________________
________________________________________________________________________
(If you do not have an attorney, write "none.")

SECTION II. RESPONDENT
(This section is about the person you want to be protected from. It must be completed.)

1. Respondent currently lives at the following address: {address, city, state, and zip code}

Family Supreme Court Approved Law Form 12.980(q), Petition for Injunction for Protection Against Sexual Violence
(03/15)
- 601 -
________________________________________________________________________
_______________________________________________________________________
Respondent’s Driver’s License number is: {if known} ____________________________________

2. Respondent's last known place of employment:________________________________________
Employment address:_____________________________________________________________
Working hours: __________________________

3. Physical description of Respondent:
Race: _____ Sex: Male ____ Female _____ Date of Birth:
Height: _____ Weight: _____ Eye Color: _____ Hair Color: ____________________
Distinguishing marks and/or scars:
Vehicle: (make/model) _______________ Color: _________ Tag Number:

4. Other names Respondent goes by (aliases or nicknames):________________________________
______________________________________________________________________________

5. Respondent's attorney’s name, address, and telephone number is: ________________________
________________________________________________________________________
(If you do not know whether Respondent has an attorney, write "unknown." If Respondent does not
have an attorney, write "none.")

6. If Respondent is a minor, the address of Respondent’s parent or legal guardian is: ____________

SECTION III. CASE HISTORY AND REASON FOR SEEKING PETITION
(This section must be completed.)

1. Petitioner has suffered sexual violence as shown by the fact that the Respondent has: {describe
the acts of violence}

.
_____ Please indicate here if you are attaching additional pages to continue these facts.

{Indicate all that apply}
a. ____ Petitioner reported the sexual violence to law enforcement and is cooperating in any
criminal proceeding. The incident report number by law enforcement is: _______________ .

b. {If there is a criminal case, include case number, if known} .

Family Supreme Court Approved Law Form 12.980(q), Petition for Injunction for Protection Against Sexual Violence
(03/15)
- 602 -
c. _____Respondent was sent to prison for committing sexual violence against Petitioner or
Petitioner’s minor child living at home and Respondent is out of prison or is getting out of
prison within 90 days. The notice of inmate release is attached.

2. Has Petitioner ever received or tried to get an injunction for protection against domestic
violence, dating violence, repeat violence, or sexual violence against Respondent in this or any other
court?
_____ Yes _____No If yes, what happened in that case? {Include case number, if known}
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.

3. Has Respondent ever received or tried to get an injunction for protection against domestic
violence, dating violence, repeat violence, or sexual violence against Petitioner in this or any other
court?
_____ Yes _____ No If yes, what happened in that case? {Include case number, if known}
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.

4. Describe any other court case that is either going on now or that happened in the past between
Petitioner and Respondent {Include case number, if known}:
______________________________________________________________________________
______________________________________________________________________________
____.

5. Additional Information
{Indicate all that apply}
a. ____Respondent owns, has, and/or is known to have guns or other weapons.
Describe weapon(s): ___________________________________________________________

b. ____This or prior acts of violence have been previously reported to: {person or agency}
______________________________________________________________________________

SECTION IV. INJUNCTION
(This section must be completed.)

1. Petitioner asks the Court to enter a TEMPORARY INJUNCTION for protection against sexual
violence that will be in place from now until the scheduled hearing in this matter.

2. Petitioner asks the Court to enter an injunction prohibiting Respondent from committing any

Florida Supreme Court Approved Family Law Form 12.980(q), Petition for Injunction for Protection Against Sexual
Violence (03/15)
- 603 -
acts of violence against Petitioner and:
a. prohibiting Respondent from going to or within 500 feet of any place Petitioner lives;

c. prohibiting Respondent from contacting Petitioner by telephone, mail, by e-mail, in writing,
through another person, or in any other manner;

d. ordering Respondent not to use or possess any guns or firearms;

{Indicate all that apply}
e. _____ prohibiting Respondent from going to or within 500 feet of the following place(s)
Petitioner or Petitioner’s immediate family must go to often: ____________________________
________________________________
;

f. _____ prohibiting Respondent from knowingly and intentionally going to or within 100
feet of Petitioner’s motor vehicle;
AND any other terms the Court deems necessary for the safety of Petitioner and Petitioner’s
immediate family.

I UNDERSTAND THAT BY FILING THIS PETITION, I AM ASKING THE COURT TO HOLD A HEARING ON
THIS PETITION, THAT BOTH THE RESPONDENT AND I WILL BE NOTIFIED OF THE HEARING, AND THAT I
MUST APPEAR AT THE HEARING. I UNDERSTAND THAT IF EITHER RESPONDENT OF I FAIL TO APPEAR
AT THE FINAL HEARING, WE WILL BE BOUND BY THE TERMS OF ANY INJUNCTION OR ORDER ISSUED
AT THAT HEARING.

Dated: _______________________
_______________________________________
Signature of Petitioner

Printed Name: ________________________________
Address: ____________________________________

Florida Supreme Court Approved Family Law Form 12.980(q), Petition for Injunction for Protection Against Sexual
Violence (03/15)
- 604 -
City, State, Zip: ________
Telephone Number: ___________________________
Fax Number: _______

Designated E-Mail Address(es): ___________________________________________

STATE OF FLORIDA
COUNTY OF _________________

Sworn to or affirmed and signed before me on_____________________ by _____________________.

NOTARY PUBLIC or DEPUTY CLERK

{Print, type, or stamp commissioned name of notary or clerk.}
______ Personally known
___ Produced identification
Type of identification produced _________

Florida Supreme Court Approved Family Law Form 12.980(q), Petition for Injunction for Protection Against Sexual
Violence (03/15)
- 605 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR __________ COUNTY, FLORIDA

Case No.:
Division:
__________________,
Petitioner,
and

___________________,
Respondent.

TEMPORARY INJUNCTION FOR PROTECTION AGAINST SEXUAL VIOLENCE

The Petition for Injunction for Protection Against Sexual Violence under Section 784.046, Florida
Statutes, and other papers filed in this Court have been reviewed. Under the laws of Florida, the Court
has jurisdiction of the petitioner and the subject matter and has jurisdiction of the respondent upon
service of the temporary injunction. The term Petitioner as used in this injunction includes the person
on whose behalf this injunction is entered.

SECTION I. NOTICE OF HEARING

Because this Temporary Injunction for Protection Against Sexual Violence has been issued without
notice to Respondent, the Petitioner and Respondent are instructed that they are scheduled to appear
and testify at a hearing regarding this matter on {date} _____________________, at __________
a.m./p.m., when the Court will consider whether to issue a Final Judgment of Injunction for Protection
Against Sexual Violence, which shall remain in effect until modified or dissolved by the Court, and
whether other things should be ordered. The hearing will be before The Honorable
{name}__________________________, at {room name/number, location, address, city}
____________________________________________________________________________, Florida. If
Petitioner and/or Respondent do not appear, this temporary injunction may be continued in force,
extended, or dismissed, and/or additional orders may be granted, including entry of a permanent
injunction and the imposition of court costs. Petitioner and Respondent will be bound by the terms of
any injunction or order issued at the final hearing. All witnesses and evidence, if any, must be presented
at this time.

IF EITHER PETITIONER OR RESPONDENT DO NOT APPEAR AT THE FINAL HEARING, HE OR SHE WILL BE

Florida Supreme Court Approved Family Law Form 12.980(r), Temporary Injunction for Protection Against Sexual
Violence (03/15)
- 606 -
BOUND BY THE TERMS OF ANY INJUNCTION OR ORDER ISSUED IN THIS MATTER.

NOTICE: Because this is a civil case, there is no requirement that these proceedings be transcribed at
public expense.

YOU ARE ADVISED THAT IN THIS COURT:

a.____a court reporter is provided by the court.

b.____electronic recording only is provided by the court. A party may arrange in advance for the
services of and provide for a court reporter to prepare a written transcript of the proceedings at that
party’s expense.

c.____ neither electronic recording nor court reporting services are provided by the court. A party may
arrange in advance for the services of and provide for a court reporter to prepare a written transcript of
the proceedings at that party’s expense.

SECTION II. FINDINGS

The statements made under oath by Petitioner make it appear that Section 784.046, Florida Statutes,
applies to the parties, that Petitioner is a victim of sexual violence by Respondent and meets the
requirements for an injunction established by law.

SECTION III. TEMPORARY INJUNCTION AND TERMS

This injunction shall be effective until the hearing set above and in no event for longer than 15 days,
unless extended by court order or unless the Respondent is incarcerated, and if incarcerated, shall be
effective for 15 days following the date Respondent is released from incarceration. If a final order of

Florida Supreme Court Approved Family Law Form 12.980(r), Temporary Injunction for Protection Against Sexual
Violence (03/15)
- 607 -
injunction is issued, the terms of this temporary injunction will be extended until service of the final
injunction is effected upon Respondent. This injunction is valid and enforceable in all counties of the
State of Florida. The terms of this injunction may not be changed by either party alone or by both
parties together. Only the Court may modify the terms of this injunction. Either party may ask the
Court to change or end this injunction.
Willful violation of the terms of this injunction, such as refusing to vacate the dwelling which the
parties share, going to Petitioner's residence, place of employment, school, or other place prohibited
in this injunction, telephoning, contacting or communicating with Petitioner, if prohibited by this
injunction, or committing an act of sexual violence against Petitioner constitutes a misdemeanor of
the first degree punishable by up to one year in jail, as provided by Sections 775.082 and 775.083,
Florida Statutes.
Any party violating this injunction may be subject to civil or indirect criminal contempt proceedings,
including the imposition of a fine or imprisonment and also may be charged with a crime punishable
by a fine, jail, or both, as provided by Florida Statutes.
ORDERED and ADJUDGED:
1. Violence Prohibited. Respondent shall not commit, or cause any other person to commit, any
acts of violence against Petitioner, including assault, aggravated assault, battery, aggravated battery,
sexual assault, sexual battery, stalking, aggravated stalking, kidnapping, or false imprisonment, or any
criminal offense resulting in physical injury or death. Respondent shall not commit any other violation
of the injunction through an intentional unlawful threat, word, or act to do violence to Petitioner.

or any residence to which Petitioner may move; Petitioner’s current or any subsequent place of
employment {list address of current employment} _____________________________________
________________________________
or place where Petitioner attends school {list address of school} ___________
;
or the following other places (if requested by Petitioner) where Petitioner or Petitioner’s minor
child(ren) go often:
______________________________________________________________________________

______________________________________________________________________________

Florida Supreme Court Approved Family Law Form 12.980(r), Temporary Injunction for Protection Against Sexual
Violence (03/15)
- 608 -
______________________________________________________________________________

{Initial if applies; write N/A if not applicable}
b. _____Respondent may not knowingly come within 100 feet of Petitioner’s automobile at any
time.

c. _____ Other provisions regarding contact:_________________________________________
________________________________________________________________________
________________________________________________________________________ .

3. Firearms.
{Initial all that apply; write N/A if does not apply}
a. ____Respondent shall not use or possess a firearm or ammunition.

b. ____Respondent shall surrender any firearms and ammunition in Respondent's possession to the
____________________County Sheriff's Department.

c. ____Other directives relating to firearms and ammunition: _______________________
____________________________________________________________________________
____________________________________________________________________________ .

4. Mailing Address or Designated E-Mail Address(es). Respondent shall notify the Clerk of the
Court of any change in either his or her mailing address, or designated e-mail address(es), within 10 days
of the change. All further papers (excluding pleadings requiring personal service) shall be served either
by mail to Respondent’s last known mailing address or by e-mail to Respondent’s designated e-mail
address(es). Service by mail shall be complete upon mailing or e-mailing.

SECTION IV. OTHER SPECIAL PROVISIONS
{This section to be used for inclusion of local provisions approved by the chief judge as provided in Florida
Family Law Rule 12.610.}
_____________________________________________________________________________
__________________________________________________________________________
___________________________________________________________________________

SECTION V. DIRECTIONS TO LAW ENFORCEMENT OFFICER IN ENFORCING THIS INJUNCTION

Florida Supreme Court Approved Family Law Form 12.980(r), Temporary Injunction for Protection Against Sexual
Violence (03/15)
- 609 -
{Unless ordered otherwise by the judge, all provisions in this injunction are considered mandatory
provisions and should be interpreted as part of this injunction.}

1. The Sheriff of ______________ County, or any other authorized officer, is ordered to serve this
temporary injunction upon Respondent as soon as possible after its issuance.

2. This injunction is valid and enforceable in all counties of the State of Florida. Violation of this
injunction should be reported to the appropriate law enforcement agency. Law enforcement officers of
the jurisdiction in which a violation of this injunction occurs shall enforce the provisions of this
injunction and are authorized to arrest without a warrant pursuant to section 901.15, Florida Statutes,
for any violation of its provisions, which constitutes a criminal act under Section 784.047, Florida
Statutes.

3. Should any Florida law enforcement officer having jurisdiction have probable cause to believe
that Respondent has knowingly violated this injunction, the officer may arrest Respondent, confine
him/her in the county jail without bail, and shall bring him/her before the Initial Appearance Judge on
the next regular court day so that Respondent can be dealt with according to law. The arresting agent
shall notify the State Attorney’s Office immediately after arrest. THIS INJUNCTION IS ENFORCEABLE IN
ALL COUNTIES OF FLORIDA AND LAW ENFORCEMENT OFFICERS MAY EFFECT ARRESTS PURSUANT TO
SECTION 901.15(6), FLORIDA STATUTES.

4. Reporting alleged violations. If Respondent violates the terms of this injunction and there has
not been an arrest, Petitioner may contact the Clerk of the Circuit Court of the county in which the
violation occurred and complete an affidavit in support of the violation or Petitioner may contact the
State Attorney’s office for assistance in filing an action for indirect civil contempt or indirect criminal
contempt. Upon receiving such a report, the State Attorney is hereby appointed to prosecute such
violations by indirect criminal contempt proceedings, or the State Attorney may decide to file a criminal
charge, if warranted by the evidence.

DONE AND ORDERED in ________________________, Florida on ______________________ .

__________________________________________
CIRCUIT JUDGE

COPIES TO:
Sheriff of ________ County

Petitioner: (or his or her attorney)
__ by U. S. Mail
__ by hand delivery in open court

Florida Supreme Court Approved Family Law Form 12.980(r), Temporary Injunction for Protection Against Sexual
Violence (03/15)
- 610 -
____ by e-mail to designated e-mail address(es)

Respondent:
__ forwarded to sheriff for service
____ State Attorney’s Office
__ Other: ________________________

I CERTIFY the foregoing is a true copy of the original Temporary Injunction for Protection Against Sexual
Violence as it appears on file in the office of the Clerk of the Circuit Court of County,
Florida, and that I have furnished copies of this order as indicated above.

CLERK OF THE CIRCUIT COURT
(SEAL)

By: _________________________________________
Deputy Clerk or Judicial Assistant

Florida Supreme Court Approved Family Law Form 12.980(r), Temporary Injunction for Protection Against Sexual
Violence (03/15)
- 611 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR ________ COUNTY, FLORIDA

Case No.:
Division:
_________________ ,
Petitioner,
and

___________________,
Respondent.

FINAL JUDGMENT OF INJUNCTION FOR PROTECTION AGAINST
SEXUAL VIOLENCE (AFTER NOTICE)

The Petition for Injunction for Protection Against Sexual Violence under Section 784.046, Florida
Statutes, and other papers filed in this Court have been reviewed. The Court has jurisdiction of the
parties and the subject matter. The term Petitioner as used in this injunction includes the person on
whose behalf this injunction is entered.

SECTION I. HEARING

This cause came before the Court for a hearing to determine whether an Injunction for Protection
Against Sexual Violence in this case should be:
____ issued ____ modified ____ extended.
The hearing was attended by:
____Petitioner
____Petitioner’s Counsel
____Respondent
____Respondent’s Counsel

SECTION II. FINDINGS

Florida Supreme Court Approved Family Law Form 12.980(s), Final Judgment of Injunction for Protection Against
Sexual Violence (After Notice) (03/15)
- 612 -
After hearing the testimony of each party present and of any witnesses, or upon consent of Respondent,
the Court finds, based on the specific facts of this case, that Petitioner is a victim of sexual violence by
Respondent and meets the requirements for an injunction established by law.

SECTION III. INJUNCTION AND TERMS

Willful violation of the terms of this injunction, such as refusing to vacate the dwelling which the
parties share, going to Petitioner's residence, place of employment, school, or other place prohibited
in this injunction, telephoning, contacting or communicating with Petitioner, if prohibited by this
injunction, or committing an act of sexual violence against Petitioner constitutes a misdemeanor of
the first degree punishable by up to one year in jail, as provided by Sections 775.082 and 775.083,
Florida Statutes.

ORDERED and ADJUDGED:

________________________________________________________________or any residence to which
Petitioner may move; Petitioner’s current or any subsequent place of employment {list address of
current employment}________________________________________________

Florida Supreme Court Approved Family Law Form 12.980(s), Final Judgment of Injunction for Protection Against
Sexual Violence (After Notice) (03/15)
- 613 -
or place where Petitioner attends school {list address of school}_________________________
_______________________________________ ;
or the following other places (if requested by Petitioner) where Petitioner or Petitioner’s minor
child(ren) go often:
______________________________________________________________________________
______________________________________________________________________________
________________________________________________________________________ .

{Initial if applies; write N/A if not applicable}
b.____ Respondent may not knowingly come within 100 feet of Petitioner's automobile at any
time.

c. ____Other provisions regarding contact:____________________________________________

3. Firearms.
{Initial all that apply; write N/A if does not apply}
a. ____Respondent shall not use or possess a firearm or ammunition.

b. ____Respondent shall surrender any firearms and ammunition in the Respondent's possession to the
____________________ County Sheriff's Department.

c. ____Other directives relating to firearms and ammunition: ____________________________
.

4. Mailing Address or Designated E-Mail Address(es). Respondent shall notify the Clerk of the
Court of any change in either his or her mailing address, or designated e-mail address(es), within 10 days
of the change. All further papers (excluding pleadings requiring personal service) shall be served either
by mail to Respondent’s last known mailing address or by e-mail to Respondent’s designated e-mail
address(es). Service shall be complete upon mailing or e-mailing.

5. Additional order(s) necessary to protect Petitioner from sexual violence: _________________
_____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ .

Florida Supreme Court Approved Family Law Form 12.980(s), Final Judgment of Injunction for Protection Against
Sexual Violence (After Notice) (03/15)
- 614 -
SECTION IV. OTHER SPECIAL PROVISIONS
{This section to be used for inclusion of local provisions approved by the chief judge as provided in Florida
Family Law Rule 12.610.}
____________________________________________________________________________________
.

1. This injunction is valid and enforceable in all counties of the State of Florida. Violation of this
injunction should be reported to the appropriate law enforcement agency. Law enforcement officers of
the jurisdiction in which a violation of this injunction occurs shall enforce the provisions of this
injunction and are authorized to arrest without a warrant pursuant to Section 901.15, Florida Statutes,
for any violation of its provision, which constitutes a criminal act under Section 784.047, Florida
Statutes.
2. Should any Florida law enforcement officer having jurisdiction have probable cause to believe
that Respondent has knowingly violated this injunction, the officer may arrest Respondent, confine
him/her in the county jail without bail, and shall bring him/her before the Initial Appearance Judge on
the next regular court day so that Respondent can be dealt with according to law. The arresting agent
shall notify the State Attorney’s Office immediately after arrest. THIS INJUNCTION IS ENFORCEABLE IN
ALL COUNTIES OF FLORIDA AND LAW ENFORCEMENT OFFICERS MAY EFFECT ARRESTS PURSUANT TO
SECTION 901.15(6), FLORIDA STATUTES.
3. Reporting alleged violations. If Respondent violates the terms of this injunction and there has
not been an arrest, Petitioner may contact the Clerk of the Circuit Court of the county in which the
violation occurred and complete an affidavit in support of the violation or Petitioner may contact the
State Attorney’s Office for assistance in filing an action for indirect civil contempt or indirect criminal
contempt. Upon receiving such a report, the State Attorney is hereby appointed to prosecute such
violations by indirect criminal proceedings, or the State Attorney may decide to file a criminal charge, if
warranted by the evidence.
4. Respondent, upon service of this injunction, shall be deemed to have knowledge of and to be
bound by all matters occurring at the hearing and on the face of this injunction.
5. The temporary injunction, if any, entered in this case is extended until such time as service of
this injunction is effected upon Respondent.

DONE AND ORDERED in ___________________________, Florida on ____________________.

_____________________________________________
CIRCUIT JUDGE

Florida Supreme Court Approved Family Law Form 12.980(s), Final Judgment of Injunction for Protection Against
Sexual Violence (After Notice) (03/15)
- 615 -
COPIES TO:
Sheriff of County

____ State Attorney’s Office
____ Other __________________________________________________

I CERTIFY the foregoing is a true copy of the original Final Judgment of Injunction for Protection Against
Sexual Violence as it appears on file in the office of the Clerk of the Circuit Court of _______
County, Florida, and that I have furnished copies of this order as indicated above.

CLERK OF THE CIRCUIT COURT
(SEAL)
By: __________________________________________
Deputy Clerk or Judicial Assistant

ACKNOWLEDGMENT

I, {Name of Petitioner} ___________________________, acknowledge receipt of a certified copy of this

Florida Supreme Court Approved Family Law Form 12.980(s), Final Judgment of Injunction for Protection Against
Sexual Violence (After Notice) (03/15)
- 616 -
Injunction for Protection.

_____________________________________________
Petitioner

ACKNOWLEDGMENT

I, {Name of Respondent} __________________________, acknowledge receipt of a certified copy of this
Injunction for Protection.

_____________________________________________
Respondent

Florida Supreme Court Approved Family Law Form 12.980(s), Final Judgment of Injunction for Protection Against
Sexual Violence (After Notice) (03/15)
- 617 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.980(t)
PETITION FOR INJUNCTION FOR PROTECTION AGAINST STALKING
(03/15)

When should this form be used?

If you are a victim of stalking, you can use this form to ask the court for a protective order prohibiting
stalking. Stalking means the repeated following, harassment, or cyberstalking of one person by another.
Cyberstalk means to engage in a course of conduct to communicate, or to cause to be communicated,
words, images, or language by or through the use of electronic mail or electronic communication,
directed at a specific person, causing substantial emotional distress to that person and serving no
legitimate purpose.

Because you are making a request to the court, you are called the petitioner. The person whom you are
asking the court to protect you from is called the respondent. If you are under the age of eighteen and
have never been married or had the disabilities of nonage removed by a court, and are living at home,
one of your parents or your legal guardian must sign this petition on your behalf.

The parent or legal guardian of any minor child who is living at home may seek an injunction for
protection against stalking on behalf of the minor child.

If the respondent is your spouse, former spouse, related to you by blood or marriage, living with you
now or has lived with you in the past (if you are or were living as a family), or the other parent of your
child(ren), whether or not you have ever been married or ever lived together, you may, instead, choose
to use the Petition for Injunction for Protection Against Domestic Violence, Florida Supreme Court
Approved Family Law Form 12.980(a), rather than this form.

This form should be typed or printed in black ink. You should complete this form (giving as much detail
as possible) and sign it the presence of a notary or in front of the clerk of the circuit court in one of the
following: the circuit where you currently or temporarily reside; the circuit where the respondent
resides; or the circuit where the stalking occurred. The clerk will take your completed petition to a
judge. You should keep a copy for your records. If have any questions or need assistance completing
this form, the clerk or family law intake staff will help you. There is no filing fee for a petition for
protection against stalking.

What should I do if the judge grants my petition?

If the facts contained in your petition convince the judge that stalking or cyberstalking exists, the judge
will sign a Temporary Injunction for Protection Against Stalking, Florida Supreme Court Approved
Family Law Form 12.980(u). A temporary injunction is issued without notice to the respondent. The clerk

Instructions for Florida Supreme Court Approved Family Law Form 12.980(t), Petition for Injunction for Protection
Against Stalking (03/15)
- 618 -
will give your petition, the temporary injunction, and any other papers filed with your petition to the
sheriff or other law enforcement officer for personal service on the respondent. The temporary
injunction will take effect immediately after the respondent is served with a copy of it. It lasts until a
hearing can be held or for a period of 15 days, whichever comes first.

The court may extend the temporary injunction beyond 15 days for a good reason, which may include
failure to obtain service on the respondent.

The temporary injunction is issued ex parte. This means that the judge has considered only the
information presented by one side--YOU. Section I of the temporary injunction gives a date that you
should appear in court for a hearing. You will be expected to testify about the facts in your petition. The
respondent will be given the opportunity to testify at this hearing also. At the hearing, the judge will
decide whether to issue a Final Judgment of Injunction for Protection Against Stalking (After Notice),
Florida Supreme Court Approved Family Law Form 12.980(v), which will remain in effect for a specific
time period or until modified or dissolved by the court. If either you or the respondent do not appear at
the hearing, the temporary injunction may be continued in force, extended, or dismissed, and/or
additional orders may be granted, including entry of a permanent injunction and the imposition of
court costs. You and the respondent will be bound by the terms of any injunction or order issued at
the final hearing.

IF EITHER YOU OR THE RESPONDENT DO NOT APPEAR AT THE FINAL HEARING, YOU WILL BOTH BE
BOUND BY THE TERMS OF ANY INJUNCTION OR ORDER ISSUED IN THIS MATTER.

If the judge signs a temporary or final injunction, the clerk will provide you with the necessary copies.
Make sure that you keep one certified copy of the injunction with you at all times!

What can I do if the judge denies my petition or
does not issue a Temporary Injunction?

If your petition is denied, you may amend your petition by filing a Supplemental Affidavit in Support of
Petition for Injunction for Protection, Florida Supreme Court Approved Family Law Form 12.980(g). If
the only ground for not granting an ex parte temporary injunction is no appearance of immediate and
present danger of stalking, the court shall set a full hearing on your petition for injunction at the earliest
possible time. The respondent will be notified by personal service of your petition and the hearing. You
must attend the hearing, present facts, and bring evidence that supports your petition; failure to attend
the hearing may result in dismissal of your petition.

Where can I look for more information?

Instructions for Florida Supreme Court Approved Family Law Form 12.980(t), Petition for Injunction for Protection
Against Stalking (03/15)
- 619 -
the circuit court or family law intake staff will help you complete any necessary forms. For further
information, see Section 784.0485, Florida Statutes, and Rule 12.610, Florida Family Law Rules of
Procedure.

IMPORTANT INFORMATION REGARDING E-FILING

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Special Notes

If you require that your address be confidential for safety reasons, you should complete a Request for
Confidential Filing of Address, Florida Supreme Court Approved Family Law Form 12.980(h), and file it
with the clerk of the circuit. You should then write confidential in the space provided on the petition.

Instructions for Florida Supreme Court Approved Family Law Form 12.980(t), Petition for Injunction for Protection
Against Stalking (03/15)
- 620 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR ______________ COUNTY, FLORIDA

Case No.:
Division:
_________________,
Petitioner,
and

__________________,
Respondent.

PETITION FOR INJUNCTION FOR PROTECTION AGAINST STALKING
I, {full legal name} , being sworn, certify that the
following statements are true:

SECTION I. PETITIONER
(This section is about you. It must be completed; however, if you require that your address be
confidential for safety reasons, you should complete and file a Request for Confidential Filing of
Address, Florida Supreme Court Approved Family Law Form 12.980(h), and write confidential in the
space provided on this form for your address and telephone number.)

1. Petitioner resides at the following address: {address, city, state, zip code}
.
{Indicate if applicable}
__Petitioner seeks an injunction for protection on behalf of a minor child. Petitioner is the parent
or legal guardian of {full legal name} ___________________,
a minor child who is living at home.

2. Petitioner's attorney's name, address, and telephone number is:
.
(If you do not have an attorney, write "none.")

SECTION II. RESPONDENT
(This section is about the person you want to be protected from. It must be completed.)

1. Respondent resides at the following address: {provide last known street address, city, state, and
zip code}
.

Florida Supreme Court Approved Family Law Form 12.980(t), Petition for Injunction for Protection Against Stalking
(03/15)
- 621 -
2. Respondent's last known place of employment:
Employment address:
Working hours of Respondent: ____________________________

3. Physical description of Respondent:
Race: Sex: Male __ Female __ Date of Birth: _________________________
Height: Weight: _ Eye Color: Hair Color:
Distinguishing marks and/or scars:
Vehicle: (make/model)__________ Color:_________ Tag Number (if known)________________

4. Other names Respondent goes by (aliases or nicknames):
______________________________________________________________________________

5. Respondent's attorney’s name, address, and telephone number is:

(If you do not know whether Respondent has an attorney, write "unknown." If Respondent does not
have an attorney, write "none.")

SECTION III. CASE HISTORY AND REASON FOR SEEKING PETITION (This section must be completed.)

1. Has Petitioner ever received or tried to get an injunction for protection against stalking against
Respondent in this or any other court?
_ Yes _ No If yes, what happened in that case? {include case number, if known}

2. Has Respondent ever received or tried to get an injunction for protection against stalking
against Petitioner in this or any other court?
_ Yes _ No If yes, what happened in that case? {include case number, if known}

3. Describe any other court case that is either going on now or that happened in the past between
Petitioner and Respondent {include case number, if known}:

______________________________________________________________________________.

4. Petitioner is a victim of stalking because Respondent has: {please mark all sections that apply}
a. ____Committed stalking;
b. ____Previously threatened, harassed, stalked, cyberstalked, or physically abused the
Petitioner;
c. ____Threatened to harm Petitioner or family members or individuals closely associated with
Petitioner;

Florida Supreme Court Approved Family Law Form 12.980(t), Petition for Injunction for Protection Against Stalking
(03/15)
- 622 -
d. ____Intentionally injured or killed a family pet;
e. ____Used, or threatened to use, against Petitioner any weapons such as guns or knives;
f. ____A criminal history involving violence or the threat or violence, if known;
g. ____Another order of protection issued against him or her previously from another
jurisdiction, if known;
h. ____ Destroyed personal property, including, but not limited to, telephones or other
communication equipment, clothing, or other items belonging to Petitioner.

5. Below is a description of the specific incidents of stalking or cyberstalking: {for cyberstalking,
please include a description of all evidence of contacts and/or threats made by Respondent in voice
messages, texts, emails, or other electronic communication}
On {dates} _____________ the following incidents of stalking occurred at the following
locations:
{the locations may include, but need not be limited to, a home, school, or place of employment}

.
_____Please indicate here if you are attaching additional pages to continue these facts.

6. Additional Information
____Respondent owns, has, and/or is known to have guns or other weapons.
Describe weapon(s) and where they may be located, if known: ___________________________
.

SECTION IV. INJUNCTION {This section must be completed}

1. Petitioner asks the Court to enter a TEMPORARY INJUNCTION for protection against stalking
that will be in place from now until the scheduled hearing in this matter, which will immediately
restrain Respondent from committing any acts of stalking, and which will provide any terms the
Court deems necessary for the protection of a victim of stalking, including any injunctions or
directives to law enforcement agencies.

2. Petitioner asks the Court to enter, after a hearing has been held on this petition, a FINAL
JUDGMENT for protection against stalking prohibiting Respondent from committing any acts of stalking
against Petitioner and:

a. prohibiting Respondent from going to or within 500 feet of any place Petitioner lives, or to
any specified place regularly frequented by Petitioner and any named family members or individuals
closely associated with Petitioner;
___________________________________________________________________________.

b. prohibiting Respondent from going to or within 500 feet of Petitioner’s place(s) of employment or the
school that Petitioner attends; the address of Petitioner's place(s) of employment and/or school is:
;

Florida Supreme Court Approved Family Law Form 12.980(t), Petition for Injunction for Protection Against Stalking
(03/15)
- 623 -
c. prohibiting Respondent from contacting Petitioner by telephone, mail, by e-mail, in writing,
through another person, or in any other manner;

d. ordering Respondent that he or she shall not have in his or her care, custody, possession, or
control any firearm or ammunition;

e. prohibiting Respondent from knowingly and intentionally going to or within 100 feet of
Petitioner’s motor vehicle, whether or not that vehicle is occupied;

3. Petitioner asks the Court to enter any other terms it deems necessary to protect Petitioner from
stalking by Respondent.

I UNDERSTAND THAT BY FILING THIS PETITION, I AM ASKING THE COURT TO HOLD A HEARING ON
THIS PETITION, THAT BOTH THE RESPONDENT AND I WILL BE NOTIFIED OF THE HEARING, AND THAT I
MUST APPEAR AT THE HEARING. I UNDERSTAND THAT IF EITHER THE RESPONDENT OR I FAIL TO
APPEAR AT THE FINAL HEARING, WE WILL BE BOUND BY THE TERMS OF ANY INJUNCTION OR ORDER
ISSUED AT THAT HEARING.

I HAVE READ EVERY STATEMENT MADE IN THIS PETITION AND EACH STATEMENT IS TRUE AND
CORRECT. I UNDERSTAND THAT THE STATEMENTS MADE IN THIS PETITION ARE BEING MADE UNDER
PENALTY OF PERJURY, PUNISHABLE AS PROVIDED IN SECTION 837.02, FLORIDA STATUTES.

Dated: ____
____________________________________________
Signature of Petitioner
Printed Name:
Address:
City, State, Zip:
Telephone Number:

Designated E-Mail Address(es): ___________________________________________________________

STATE OF FLORIDA
COUNTY OF

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

[Print, type, or stamp commissioned name of notary or clerk.]
__ Personally known
__ Produced identification
Type of identification produced

Florida Supreme Court Approved Family Law Form 12.980(t), Petition for Injunction for Protection Against Stalking
(03/15)
- 624 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR ___________ COUNTY, FLORIDA

Case No.:
Division:
__________________,
Petitioner,
and

__________________,
Respondent.

TEMPORARY INJUNCTION FOR PROTECTION AGAINST STALKING
The Petition for Injunction for Protection Against Stalking under Section 784.0485, Florida Statutes, and
other papers filed in this Court have been reviewed. Under the laws of Florida, the Court has jurisdiction
of the Petitioner and the subject matter, and has jurisdiction of the Respondent upon service of the
temporary injunction. The term Petitioner as used in this injunction includes the person on whose
behalf this injunction is entered.

SECTION I. NOTICE OF HEARING

Because this Temporary Injunction for Protection Against Stalking has been issued without notice to
Respondent, Petitioner and Respondent are instructed that they are scheduled to appear and testify at a
hearing regarding this matter on {date} _______________________, at ________ a.m./p.m., when the
Court will consider whether it should issue a Final Judgment of Injunction for Protection Against Stalking,
which shall remain in effect until modified or dissolved by the Court, and whether other things should be
ordered. The hearing will be before The Honorable {name} ___________________________, at the
following address:
__________________________________________________________________, Florida. If Petitioner
and/or Respondent do not appear, this temporary injunction may be continued in force, extended, or
dismissed, and/or additional orders may be granted, including entry of a permanent injunction and the
imposition of court costs. All witnesses and evidence, if any, must be presented at this time. Petitioner
and Respondent will be bound by the terms of any injunction or order issued at the final hearing.

IF EITHER PETITIONER OR RESPONDENT DO NOT APPEAR AT THE FINAL HEARING, HE OR SHE WILL BE
BOUND BY THE TERMS OF ANY INJUNCTION OR ORDER ISSUED IN THIS MATTER.

NOTICE: Because this is a civil case, there is no requirement that these proceedings be transcribed at

Florida Supreme Court Approved Family Law Form 12.980(u), Temporary Injunction for Protection Against Stalking
(03/15)
- 625 -
public expense.
YOU ARE ADVISED THAT IN THIS COURT:

a.____ a court reporter is provided by the court.

b.____ electronic recording only is provided by the court. A party may arrange in advance for the
services of and provide for a court reporter to prepare a written transcript of the proceedings at that
party’s expense.

The statements made under oath by Petitioner make it appear that Section 784.0485, Florida Statutes,
applies to the parties, and that stalking exists.

SECTION III. TEMPORARY INJUNCTION AND TERMS

This injunction shall be in effect until the hearing set above and in no event for longer than 15 days,
unless extended by court order. If a final order of injunction is issued, the terms of this temporary
injunction will be extended until service of the final injunction is effected upon Respondent. This
injunction is valid and enforceable in all counties of the State of Florida. The terms of this injunction
may not be changed by either party alone or by both parties together. Only the Court may modify the
terms of this injunction. Either party may ask the Court to change or end this injunction.
Willful violation of the terms of this injunction, such as: committing an act of stalking against
Petitioner; going to or being within 500 feet of Petitioner's residence, place of employment, school, or
other place prohibited in this injunction; knowingly and intentionally coming within 100 feet of
Petitioner’s motor vehicle, whether or not that vehicle is occupied; committing any other violation of
this injunction through an intentional unlawful threat, word or act to do violence to Petitioner;
telephoning, contacting or communicating with Petitioner, unless indirect contact through a third

Florida Supreme Court Approved Family Law Form 12.980(u), Temporary Injunction for Protection Against Stalking
(03/15)
- 626 -
party is specifically allowed by this injunction; defacing or destroying Petitioner’s personal property,
including Petitioner’s motor vehicle; or refusing to surrender firearms or ammunition if ordered to so
by the Court, constitutes a misdemeanor of the first degree punishable as provided by Sections
775.082 and 775.083, Florida Statutes.
Any party violating this injunction may be subject to civil or indirect criminal contempt proceedings,
including the imposition of a fine or imprisonment, and also may be charged with a crime punishable
by a fine, jail, or both, as provided by Florida Statutes.
ORDERED and ADJUDGED:
1. Prohibited Actions. Respondent shall not commit, or cause any other person to commit, any
acts of stalking against Petitioner, including stalking, cyberstalking, aggravated stalking, or any
criminal offense resulting in physical injury or death. Respondent shall not commit any other
violation of this injunction through an intentional unlawful threat, word, or act to do violence to
Petitioner.

b. Petitioner’s current residence {list address}
________________________________________________________________________
or any residence to which Petitioner may move;

c. Petitioner’s current or any subsequent place of employment {list address of current employment}
________________________________________________________________________

d. where Petitioner attends school {list address of school}
______________________________________________________________________ ; or

e. the following other places (if requested by Petitioner) where Petitioner, specific members of Petitioner’s
family, or individuals closely associated with Petitioner, regularly frequent:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________.

f. Respondent shall not knowingly and intentionally come within 100 feet of Petitioner’s motor vehicle
at any time, whether or not that vehicle is occupied;

Florida Supreme Court Approved Family Law Form 12.980(u), Temporary Injunction for Protection Against Stalking
(03/15)
- 627 -
g. Other provisions regarding contact: _____________________________________________
___________________________________________________________________________
_ .

3. Firearms.
{Initial all that apply; write N/A if not applicable}
a. ____Respondent is a state or local officer, as defined in section 943.10(14), Florida Statutes,
who holds an active certification, who receives or possesses a firearm or ammunition for use in
performing official duties on behalf of the officer’s employing agency, and is not prohibited by the court
from having in his or her care, possession, or control any firearm or ammunition.

b. ____Respondent shall not use or possess a firearm or ammunition.

c. ____Respondent shall surrender any firearms and ammunition in the Respondent's
possession to the___________________ County Sheriff's Department.

d. _____Other directives relating to firearms and ammunition: ____________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

4. Mailing Address. Respondent shall notify the Clerk of the Court of any change in his or her
mailing address within 10 days of the change. All further papers (excluding pleadings requiring personal
service) shall be served by mail to Respondent’s last known address of record. Such service by mail shall
be complete upon mailing. Rule 12.080, Florida Family Law Rules of Procedure; Section 784.0485,
Florida Statutes.

5. Additional order(s) necessary to protect Petitioner from stalking:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

6. Referral to Appropriate Services for Petitioner:
Petitioner may contact the following services as needed:
____________________________________________________________________________
_____________________________________________________________________________ .

Florida Supreme Court Approved Family Law Form 12.980(u), Temporary Injunction for Protection Against Stalking
(03/15)
- 628 -
__________________________________________________________________________________
__________________________________________________________________________________.

SECTION V. DIRECTIONS TO LAW ENFORCEMENT OFFICER IN ENFORCING THIS INJUNCTION
(Unless ordered otherwise by the judge, all provisions in this injunction are considered mandatory
provisions and should be interpreted as part of this injunction.)

1. The Sheriff of ______________ _____County, or any other authorized law enforcement officer,
is ordered to serve this temporary injunction upon Respondent as soon as possible after its issuance.

3. THIS INJUNCTION IS ENFORCEABLE IN ALL COUNTIES OF FLORIDA AND LAW ENFORCEMENT
OFFICERS MAY EFFECT ARRESTS PURSUANT TO SECTION 901.15(6), FLORIDA STATUTES. The arresting
agent shall notify the State Attorney’s Office immediately after arrest.

4. Reporting alleged violations. If Respondent violates the terms of this injunction and has not
been arrested, Petitioner may contact the clerk of the circuit court of the county in which the violation is
alleged to have occurred. The clerk shall assist Petitioner in preparing an affidavit in support of reporting
the violation or direct Petitioner to the office operated by the court that has been designated by the
chief judge of that circuit as the central intake point for violations of injunctions for protection where
Petitioner can receive assistance in the preparation of the affidavit in support of the violation. The
affidavit shall be immediately forwarded by the office assisting Petitioner to the state attorney of that
circuit and to the judge designated by the chief judge as the recipient of affidavits of violations of an
injunction. Procedures relating to reporting alleged violations are governed by section 784.0487, Florida
Statutes.

DONE AND ORDERED in ____________________________, Florida, on _________________ .

CIRCUIT JUDGE

COPIES TO:
Sheriff of ________ County

Florida Supreme Court Approved Family Law Form 12.980(u), Temporary Injunction for Protection Against Stalking
(03/15)
- 629 -
Petitioner:
__ by U. S. Mail
__ by hand delivery in open court
Respondent:
__ forwarded to sheriff for service
____ State Attorney’s Office
__ Other:

I CERTIFY the foregoing is a true copy of the original Temporary Injunction for Protection Against
Stalking as it appears on file in the office of the Clerk of the Circuit Court of __________________
County, Florida, and that I have furnished copies of this order as indicated above.

CLERK OF THE CIRCUIT COURT
(SEAL)

By:_______________________________________
Deputy Clerk

Florida Supreme Court Approved Family Law Form 12.980(u), Temporary Injunction for Protection Against Stalking
(03/15)
- 630 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR __________ COUNTY, FLORIDA

Case No.:
Division:
___________________,
Petitioner,
and

__________________,
Respondent.

FINAL JUDGMENT OF INJUNCTION FOR PROTECTION AGAINST
STALKING (AFTER NOTICE)

The Petition for Injunction for Protection Against Stalking under Section 784.0485, Florida Statutes, and
other papers filed in this Court have been reviewed. The Court has jurisdiction of the parties and the
subject matter. The term Petitioner as used in this injunction includes the person on whose behalf this
injunction is entered.

SECTION I. HEARING

This cause came before the Court for a hearing to determine whether an Injunction for Protection
Against Stalking in this case should be:
____ issued ____ modified____ extended.
The hearing was attended by:
____Petitioner
____Petitioner’s Counsel
____Respondent
____Respondent’s Counsel

SECTION II. FINDINGS

Florida Supreme Court Approved Family Law Form 12.980(v), Final Judgment of Injunction for Protection Against
Stalking (After Notice) (03/15)
- 631 -
time required by Florida law, and Respondent was afforded an opportunity to be heard.

After hearing the testimony of each party present and of any witnesses, or upon consent of
Respondent, the Court finds, based on the specific facts of this case, that Petitioner is a victim of
stalking.

SECTION III. INJUNCTION AND TERMS

This injunction shall be in full force and effect until either ____ further order of the Court or ____ until
{date} ___________________. This injunction is valid and enforceable throughout all counties in the
State of Florida. The terms of this injunction may not be changed by either party alone or by both
parties together. Only the Court may modify the terms of this injunction. Either party may ask the
Court to change or end this injunction.

Willful violation of the terms of this injunction, such as: committing an act of stalking against
Petitioner; going to or being within 500 feet of Petitioner's residence, place of employment, school, or
other place prohibited in this injunction; knowingly and intentionally coming within 100 feet of
Petitioner’s motor vehicle, whether or not that vehicle is occupied; committing any other violation of
this injunction through an intentional unlawful threat, word or act to do violence to Petitioner;
telephoning, contacting or communicating with Petitioner, unless indirect contact through a third
party is specifically allowed by this injunction; defacing or destroying Petitioner’s personal property,
including Petitioner’s motor vehicle; having care, custody, use or possession of a firearm or
ammunition unless authorized by section 790.233(3), Florida Statutes, constitutes a misdemeanor of
the first degree punishable as provided by Sections 775.082 and 775.083, Florida Statutes.

ORDERED and ADJUDGED:
1. Prohibited Actions. Respondent shall not commit, or cause any other person to commit, any
acts of stalking against Petitioner, including stalking, cyberstalking, aggravated stalking, or any
criminal offense resulting in physical injury or death. Respondent shall not commit any other
violation of the injunction through an intentional unlawful threat, word or act to do violence to
Petitioner.

2. No Contact. Respondent shall have no contact with Petitioner unless otherwise provided in
this section.

a. Unless otherwise provided herein, Respondent shall have no contact with Petitioner.
Respondent shall not directly or indirectly contact Petitioner in person, by mail, e-mail, fax, telephone,
through another person, or in any other manner, including any electronic means or use of social media.
Further, Respondent shall not contact or have any third party contact anyone connected with

Florida Supreme Court Approved Family Law Form 12.980(v), Final Judgment of Injunction for Protection Against
Stalking (After Notice) (03/15)
- 632 -
Petitioner's employment or school to inquire about Petitioner or to send any messages to Petitioner.
Unless otherwise provided herein, Respondent shall not go to, in, or within 500 feet of:
b. Petitioner’s current residence {list address} ____________________________________

or any residence to which Petitioner may move;

c. Petitioner’s current or any subsequent place of employment {list address of current
employment} ______________________________________________________________ ;

d. Petitioner’s school {list address of school}
______________________________________________________________________ ; or

e. the following other place(s) regularly frequented by Petitioner and any named family
members or individuals closely associated with Petitioner:
_________________________________________________________________________

___________________________________________________________________________.

f. Respondent shall not knowingly or intentionally come within 100 feet of Petitioner’s motor
vehicle, whether or not that vehicle is occupied;

g. Respondent shall not deface or destroy Petitioner’s personal property, including Petitioner’s
motor vehicle

h. Other provisions regarding contact: _________________

3. Firearms.
Unless paragraph a. is initialed below, Respondent shall not have in his or her care, custody,
possession, or control any firearm or ammunition. It is a violation of section 790.233, Florida Statutes,
and a first degree misdemeanor, for Respondent to have in his or her care, custody, possession or
control any firearm or ammunition.

{Initial all that apply; write N/A if not applicable}
a. _____ Respondent is a state or local officer, as defined in section 943.10(14), Florida
Statutes, who holds an active certification, who receives or possesses a firearm or ammunition for use in
performing official duties on behalf of the officer’s employing agency, and is not prohibited by the court
from having in his or her care, custody, possession or control any firearm or ammunition.

b. _____Respondent shall not use or possess a firearm or ammunition.

Florida Supreme Court Approved Family Law Form 12.980(v), Final Judgment of Injunction for Protection Against
Stalking (After Notice) (03/15)
- 633 -
c. _____Respondent shall surrender any firearms and ammunition in the Respondent's possession
to the___________________ County Sheriff's Department. Failure to surrender either firearms or
ammunition if ordered to do so by the court constitutes a misdemeanor of the first degree, punishable
as provided in section 775.082 or 775.083, Florida Statutes.

d. _____Other directives relating to firearms and ammunition: _____________
___________________________________________________________________________
___________________________________________________________________________.

4. Treatment, Intervention, or Counseling.
{Initial if applicable; write N/A if not applicable}
a. _____Respondent shall participate in the treatment, intervention, or counseling specified
below. Respondent shall pay for all services rendered: _____________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________ .

b. Within _____ days of the date of this Injunction, Respondent shall enroll in, and thereafter
complete without delay, the treatment, intervention, or counseling required in paragraph a. above.
Respondent shall provide proof of such enrollment to the Clerk of the Court.

6. Additional provisions(s) necessary to protect Petitioner from stalking:
_____________________________________________________________________________
_____________________________________________________________________________

7. Referral to Appropriate Services for Petitioner. Petitioner may contact the following services
as needed:
_____________________________________________________________________________
______________________________________________________________________________ .

Florida Supreme Court Approved Family Law Form 12.980(v), Final Judgment of Injunction for Protection Against
Stalking (After Notice) (03/15)
- 634 -
____________________________________________________________________________________ .

1. This injunction is valid and enforceable in all counties of the State of Florida. Violation of this
injunction should be reported to the appropriate law enforcement agency. Law enforcement officers of
the jurisdiction in which a violation of this injunction occurs shall enforce the provisions of this
injunction and are authorized to arrest without a warrant pursuant to Section 901.15, Florida Statutes,
for any violation of its provisions, which constitutes a criminal act under Section 784.0485, Florida
Statutes.
2. THIS INJUNCTION IS ENFORCEABLE IN ALL COUNTIES OF FLORIDA AND LAW ENFORCEMENT
OFFICERS MAY EFFECT ARRESTS PURSUANT TO SECTION 901.15(6), FLORIDA STATUTES. The arresting
agent shall notify the State Attorney’s Office immediately after arrest.
3. Reporting alleged violations. If Respondent violates the terms of this injunction and has not
been arrested, Petitioner may contact the clerk of the circuit court of the county in which the violation is
alleged to have occurred. The clerk shall assist Petitioner in preparing an affidavit in support of reporting
the violation or direct Petitioner to the office operated by the court that has been designated by the
chief judge of that circuit as the central intake point for violations of injunctions for protection where
Petitioner can receive assistance in the preparation of the affidavit in support of the violation. The
affidavit shall be immediately forwarded by the office assisting Petitioner to the state attorney of that
circuit and to the judge designated by the chief judge as the recipient of affidavits of violations of an
injunction. Procedures relating to reporting alleged violations are governed by section 784.0487, Florida
Statutes.
4. Respondent, upon service of this injunction, shall be deemed to have knowledge of and to be
bound by all matters occurring at the hearing and on the face of this injunction.
5. The temporary injunction, if any, entered in this case is extended until such time as service of
this injunction is effected upon Respondent.

DONE AND ORDERED in____________________________, Florida, on ____________________.

__________________________________________
CIRCUIT JUDGE

Florida Supreme Court Approved Family Law Form 12.980(v), Final Judgment of Injunction for Protection Against
Stalking (After Notice) (03/15)
- 635 -
COPIES TO:
Sheriff of _____ County

Petitioner (or his or her attorney):
_____ by U. S. Mail
_____ by hand delivery in open court (Petitioner must acknowledge receipt in writing on the face of the
original order--see below.)
_____ by e-mail to designated e-mail address(es)

Respondent (or his or her attorney):
___ __forwarded to sheriff for service
_____ by hand delivery in open court (Respondent must acknowledge receipt in writing on the face of
the original order--see below.)
_____ by certified mail (may only be used when Respondent is present at the hearing and Respondent
fails or refuses to acknowledge the receipt of a certified copy of this injunction.)

_____ State Attorney’s Office
_____ Other __________________________

I CERTIFY the foregoing is a true copy of the original Final Judgment of Injunction for Protection Against
Stalking as it appears on file in the office of the Clerk of the Circuit Court of ____________
County, Florida, and that I have furnished copies of this order as indicated above.

CLERK OF THE CIRCUIT COURT
(SEAL)

By:_______________________________________
Deputy Clerk or Judicial Assistant

ACKNOWLEDGMENT

I, {Name of Petitioner} ___________________________, acknowledge receipt of a certified copy of this
Final Judgment of Injunction for Protection Against Stalking.

Florida Supreme Court Approved Family Law Form 12.980(v), Final Judgment of Injunction for Protection Against
Stalking (After Notice) (03/15)
- 636 -
Petitioner

ACKNOWLEDGMENT

I, {Name of Respondent} __________________________, acknowledge receipt of a certified copy of this
Final Judgment of Injunction for Protection Against Stalking.

Respondent

Florida Supreme Court Approved Family Law Form 12.980(v), Final Judgment of Injunction for Protection Against
Stalking (After Notice) (03/15)
- 637 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.980(w)
PETITION BY AFFIDAVIT FOR ORDER TO SHOW CAUSE FOR A
VIOLATION OF FINAL JUDGMENT OF INJUNCTION FOR PROTECTION
AGAINST DOMESTIC, REPEAT, DATING, OR SEXUAL VIOLENCE, OR
STALKING (03/15)

When should this form be used?

You may use this form if you have a valid Final Judgment of Injunction for Protection Against Domestic,
Repeat, Dating, or Sexual Violence, or Stalking, in force which has been violated. You should use this
affidavit to state the essential facts which establish a violation of the Final Judgment of Injunction.

This form should be typed or printed in black ink. After completing this form, you should sign the form
before a notary public or the clerk of the circuit court. You should then file the original with such clerk
or judge as determined by the chief judge of your circuit to be the recipient of affidavits of violation,
provide a copy to the state attorney of that circuit and keep a copy for your records.

IMPORTANT INFORMATION REGARDING E-FILING

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions for Florida Supreme Court Approved Family Law Form 12.980(w), Petition by Affidavit for Order to
Show Cause for a Violation of Final Judgment of Injunction for Protection Against Domestic, Repeat, Dating, or
Sexual Violence, or Stalking (03/15)
- 638 -
To serve and receive documents by e-mail, you must designate your e-mail addresses by using the
Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family Law Form
12.915, and you must provide your e-mail address on each form on which your signature appears.
Please CAREFULLY read the rules and instructions for: Certificate of Service (General), Florida Supreme
Court Approved Family Law Form 12.914; Designation of Current Mailing and E-mail Address, Florida
Supreme Court Approved Family Law Form 12.915; and Florida Rule of Judicial Administration 2.516.

Instructions for Florida Supreme Court Approved Family Law Form 12.980(w), Petition by Affidavit for Order to
Show Cause for a Violation of Final Judgment of Injunction for Protection Against Domestic, Repeat, Dating, or
Sexual Violence, or Stalking (03/15)
- 639 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR _________ COUNTY, FLORIDA

Case No.:

Division:
________ ,
Petitioner,
and

,
Respondent.

PETITION BY AFFIDAVIT FOR ORDER TO SHOW CAUSE FOR A
VIOLATION OF FINAL JUDGMENT OF INJUNCTION FOR PROTECTION
AGAINST
( ) DOMESTIC VIOLENCE ( ) REPEAT VIOLENCE
( ) DATING VIOLENCE ( ) SEXUAL VIOLENCE ( ) STALKING

I, {full legal name} ___________________________________________, being sworn, certify that I have
actual knowledge of the following facts as set forth and the following statements are true:

1. The Court previously issued a {Choose one only}
a. ____ Final Judgment of Injunction for Protection Against Domestic Violence
b. ____ Final Judgment of Injunction for Protection Against Repeat Violence
c. ____ Final Judgment of Injunction for Protection Against Dating Violence
d. ____ Final Judgment of Injunction for Protection Against Sexual Violence
e. ____ Final Judgment of Injunction for Protection Against Stalking
in this case on {date} ______________________.

The Final Judgment of Injunction for Protection was served on Respondent on {date} _______________.

2. On {dates} _________________________, at {place and address} _______________________
____________________________________________________________________________ ,
the following event(s) took place: _________________________________________________

Florida Supreme Court Approved Family Law Form 12.980(w), Petition By Affidavit for Order to Show Cause for a
Violation of Final Judgment of Injunction for Protection Against Domestic, Repeat, Dating, or Sexual Violence, or
Stalking (03/15)
- 640 -
.
{For cyberstalking, please include a description of all evidence of contacts and/or threats made by
Respondent in voice messages, texts, emails, or other electronic communication}
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________ .
_____Please indicate here if you are attaching additional pages to continue these facts.

3. Respondent has willfully violated the Injunction by: {explain what Respondent did that violated
the Order of Protection}
____________________________________________________________________________

.
_____Please indicate here if you are attaching additional pages to continue these facts.

5. ____ Please indicate here if you are attaching copies of medical records for treatment you may
have received for injuries referred to in your affidavit, or copies of any police or sheriff reports
concerning incidents of violence involving you and Respondent.

6. Respondent acted to impair, interfere with, delay, hinder, lessen the authority of, dignity of, and
embarrass the cause of justice in a manner contemptuous of this court.

WHEREFORE, I respectfully request that the Court issue an Order to Show Cause, requiring Respondent
to appear before the Court to show cause why Respondent should not be held in contempt of court for
failure to abide by the terms and conditions of the Final Judgment of Injunction for Protection.

I understand that by filing this affidavit, I am asking the court to hold a hearing, that both Respondent
and I will be notified of the hearing, and that I must appear at the hearing. In addition to my own
testimony, I understand that I can bring other proof of the violation such as, for example, people who
saw Respondent violate the order, pictures, medical records, police reports, or anything might help
show the judge how Respondent violated the Final Judgment of Injunction for Protection.

I have read every statement made in this affidavit and each statement is true and correct. I
understand that the statements made in this affidavit are being made under penalty of perjury,
punishable as provided in Section 837.02, Florida Statutes and that the punishment for knowingly

Dated: ___________________________

______________________________________
Signature of Petitioner

STATE OF FLORIDA
COUNTY OF

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

{Print, type, or stamp commissioned name of notary or clerk.}

__ Personally known
__ Produced identification
Type of identification produced

I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand
delivered to the person(s) listed below on {date} ___________________.

Other party or his/her attorney:
Name:
Address:
City, State, Zip:
Fax Number:
Designated E-mail Address(es):__________________
__________________________________________

Florida Supreme Court Approved Family Law Form 12.980(w), Petition By Affidavit for Order to Show Cause for a
Violation of Final Judgment of Injunction for Protection Against Domestic, Repeat, Dating, or Sexual Violence, or
Stalking (03/15)
- 642 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR _________________ COUNTY, FLORIDA

Case No.:
Division:

___________ ,
Petitioner,
and

____________ ,
Respondent.

Description of Respondent:
Sex: ______ Eye color: _______ Height: ________ DOB: __________
Race: _________ Hair color: _________ Weight: _______
Last known address: _______________________________

ORDER TO SHOW CAUSE
This cause comes before the court for review based upon the alleged conduct of Respondent for the
issuance of an Order to Show Cause directed to {name} for
violation of the Final Judgment of Injunction for Protection as is more specifically set forth in the
Petition By Affidavit For Order To Show Cause For a Violation Of Final Judgment Of Injunction For
Protection, a copy of which is attached hereto and made a part hereof.

NOW, THEREFORE, you, {name} _________________________________________________________,
are hereby ORDERED to appear before this court before Judge {name} ,
on {date} __________________, at {time} ___.m., in Room ______ of the _______________Courthouse,
located at ______________________________________________________________, to be arraigned.
A subsequent hearing will be scheduled requiring Respondent to show cause why he/she should not be
held in contempt of this court for violation of the Final Judgment of Injunction for Protection as is stated
in the attached Petition By Affidavit For Order To Show Cause For a Violation of Final Judgment of
Injunction For Protection. Punishment, if imposed, may include a fine and incarceration. Should the
court determine, based on the evidence presented at the hearing, that Respondent’s conduct warrants
sanctions for civil contempt in addition to or instead of indirect criminal contempt, the court reserves
the right to find Respondent guilty of civil contempt and impose appropriate civil sanctions.

_____The court hereby appoints the State Attorney’s Office to prosecute the case.

_____Respondent is advised that he/she is entitled to be represented by counsel.

If you are a person with a disability who needs any accommodation to
participate in this proceeding, you are entitled, at no cost to you, to the
Florida Supreme Court Approved Family Law Form 12.980(w), Petition By Affidavit for Order to Show Cause for a
Violation of Final Judgment of Injunction for Protection Against Domestic, Repeat, Dating, or Sexual Violence, or
Stalking (03/15)
- 643 -
provision of certain assistance. Please contact:

DONE AND ORDERED in __________________ County, Florida, on {date} _________.

___________________________________________
Circuit Judge

Copies to:
Sheriff of ________________ County

Petitioner or Counsel for Petitioner:
_____by U.S. Mail
_____by e-mail to designated e-mail address(es)

Respondent or Counsel for Respondent:
_____forwarded to the sheriff for service

____State Attorney’s Office

I CERTIFY the foregoing is a true copy of the original Order to Show Cause as it appears on file in the
office of the Clerk of the Circuit Court of _________________________, County, Florida, and that I have
furnished copies of this order as indicated above.

CLERK OF THE CIRCUIT COURT

_____________________________________________
By: Deputy Clerk or Judicial Assistant

Florida Supreme Court Approved Family Law Form 12.980(w), Petition By Affidavit for Order to Show Cause for a
Violation of Final Judgment of Injunction for Protection Against Domestic, Repeat, Dating, or Sexual Violence, or
Stalking (03/15)
- 644 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.981(a)(1)
STEPPARENT ADOPTION: CONSENT AND WAIVER BY PARENT (03/15)

When should this form be used?

This form is to be completed and signed by the parent who is giving up all rights to, custody of, and
time- sharing with the minor child to be adopted. This consent shall not be executed before the birth of
the minor child. For more information about consenting to adoption, you should refer to Chapter 63,
Florida Statutes, and sections 63.062 - 63.082, Florida Statutes, in particular.

This form should be typed or printed in black ink. It must be signed in the presence of a notary public or
deputy clerk and two witnesses other than the notary or clerk. You should file this form with the Joint
Petition for Adoption by Stepparent, Florida Supreme Court Approved Family Law Form 12.981(b)(1).

After completing this form, you should hand deliver a copy or duplicate original to the parent giving
consent and have them sign the original saying they received a copy. Then you should file the original
with the clerk of the circuit court in the county where the Joint Petition for Adoption by Stepparent,
Florida Supreme Court Approved Family Law Form 12.981(b)(1) is filed and keep a copy for your records.

IMPORTANT INFORMATION REGARDING E-FILING

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

To serve and receive documents by e-mail, you must designate your e-mail addresses by using the
Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family Law Form

Instructions for Florida Supreme Court Approved Family Law Form 12.981(a)(1), Stepparent Adoption: Consent and
Waiver by Parent (03/15)
- 645 -
12.915, and you must provide your e-mail address on each form on which your signature appears.
Please CAREFULLY read the rules and instructions for: Certificate of Service (General), Florida Supreme
Court Approved Family Law Form 12.914; Designation of Current Mailing and E-mail Address, Florida
Supreme Court Approved Family Law Form 12.915; and Florida Rule of Judicial Administration 2.516.

Special notes...

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.981(a)(1), Stepparent Adoption: Consent and
Waiver by Parent (03/15)
- 646 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:

IN THE MATTER OF THE ADOPTION OF

_________________________________________
{use name to be given to minor child(ren)} Adoptee(s).

CONSENT AND WAIVER BY PARENT
1. I, {full legal name} , am the {Choose only one}
_____ father or _____ mother of the minor child(ren) subject to this consent who is/are:

Child’s Current Name Gender Birth date Birthplace
{city, county, state}
a.
b.
c.
d.
e.
f.

2. I relinquish all rights to, custody of, and time sharing with this (these) minor child(ren),
{name(s)} ______________________________________________________________________,
with full knowledge of the legal effect of the stepparent adoption and consent to the adoption
by the child(ren)’s stepparent whose name is: {Choose only one}
_____ {name}
_____ not required for my granting of this consent.

3. I understand my legal rights as a parent and I understand that I do not have to sign this consent
and release of my parental rights. I acknowledge that this consent is being given knowingly,
freely, and voluntarily. I further acknowledge that my consent is not given under fraud or
duress. I understand that there is a “grace period” in Florida during which I may revoke my
consent. If the child to be adopted is older than 6 months at the time of consent, this grace
period is for 3 days or until the child has been placed with the prospective adoptive parents,
whichever is later. I understand that, in signing this consent, I am permanently and forever
giving up all my parental rights to and interest in this (these) minor child(ren) and that this
consent may only be withdrawn if the Court finds it was obtained by fraud or duress. I
voluntarily, permanently relinquish all my parental rights to this (these) minor child(ren).

Florida Supreme Court Approved Family Law Form 12.981(a)(1), Stepparent Adoption: Consent and Waiver by
Parent (03/15)
- 647 -
4. I consent, release, and give up permanently, of my own free will, my parental rights to this
(these) minor child(ren), for the purpose of stepparent adoption.

5. I waive any further notice of the stepparent adoption proceeding.

6. I understand that pursuant to Chapter 63, Florida Statutes, “an action or proceeding of any kind
to vacate, set aside, or otherwise nullify a judgment of adoption or an underlying judgment
terminating parental rights on any ground may not be filed more than 1 year after entry of the
judgment terminating parental rights.”

7. I understand I have the right to choose a person who does not have an employment,
professional, or personal relationship with the adoption entity or the prospective adoptive
parents to be present when this affidavit is executed and to sign it as a witness. The witness I
selected is: {full legal name} _________________________________________________.

I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
consent and waiver and that the punishment for knowingly making a false statement includes fines
and/or imprisonment.

Dated: _____________________________ Signature of Parent: ______________________
Printed Name: __________________________
Address: _______________________________
City, State, Zip: __________________________
Telephone Number: ______________________
Fax Number: ____________________________
Designated E-mail Address(es): _____________
____________________________________

______________________________________ ______________________________________
Signature of Witness Signature of Witness
Printed Name: _________________________ Printed Name: _________________________
Business Address: _______________________ Business Address: _______________________
Home Address: _________________________ Home Address: _________________________
Driver’s License No.: _____________________ Driver’s License No.: _____________________
State ID Card No.: _______________________ State ID Card No.: _______________________

Florida Supreme Court Approved Family Law Form 12.981(a)(1), Stepparent Adoption: Consent and Waiver by
Parent (03/15)
- 648 -
STATE OF FLORIDA
COUNTY OF

Sworn to or affirmed and signed before me on {date} .

NOTARY PUBLIC or DEPUTY CLERK

{Print, type, or stamp commissioned name of notary or
deputy clerk.}

_ Personally known
_ Produced identification
Type of identification produced

I hereby acknowledge receipt of a copy or duplicate original of this executed Consent and Waiver.

__________________________________
Signature of Parent

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Mother ( ) Father
This form was completed with the assistance of:
{name of individual}___________________________________________________________ ,
{name of business} _____________________________________________________________ ,
{address} _______________________________________________ ,
{city} _____________,{state} _____, {zip code}_____________{telephone number} _______________.

Florida Supreme Court Approved Family Law Form 12.981(a)(1), Stepparent Adoption: Consent and Waiver by
Parent (03/15)
- 649 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.981(a)(2),
STEPPARENT ADOPTION: CONSENT OF ADOPTEE (03/15)

When should this form be used?

This form must be completed and signed by the person being adopted, the adoptee, if he or she is over
12 years of age, unless the court, in the best interest of the minor excuses the minor’s consent. It must
be signed in the presence of a notary public or deputy clerk and two witnesses other than the notary
public or deputy clerk.

This form should be typed or printed in black ink. After completing this form, you should file the original
with the clerk of the circuit court in the county where the Joint Petition for Adoption by Stepparent,
Florida Supreme Court Approved Family Law Form 12.981(b)(1) is filed and keep a copy for your records.

IMPORTANT INFORMATION REGARDING E-FILING

Special notes...

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.981(a)(2), Stepparent Adoption:
Consent of Adoptee (03/15)
- 650 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:

IN THE MATTER OF THE ADOPTION OF

_____________________________________
{use name to be given to the child(ren)} Adoptee(s).

CONSENT OF ADOPTEE

1. I, {full legal name} , being over the age of 12,
consent to my adoption by {name} , to be his/her legal
child and heir at law.

2. I have been told of my right to choose a person who does not have an employment,
professional, or personal relationship with the adoption entity or prospective adoptive parents
to be present when this affidavit is executed and to sign it as a witness. The witness I selected is:
{full legal name} .

3. {Choose only one]
_____ I consent to my name being legally changed to {specify} .
_____ I do not consent to a name change.

I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
consent and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.
Dated:
Signature of Adoptee
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es): ____________________
_______________________________________

Florida Supreme Court Approved Family Law Form 12.981(a)(2), Stepparent Adoption: Consent of Adoptee (03/15)
- 651 -
______________________________________ ______________________________________
Signature of Witness Signature of Witness
Printed Name: _________________________ Printed Name: _________________________
Business Address: _______________________ Business Address: _______________________
Home Address:_________________________ Home Address:______________________
Driver’s License No.: _____________________ Driver’s License No.: _____________________
State ID Card No.: _______________________ State ID Card No.: _______________________

STATE OF FLORIDA
COUNTY OF ______________ _________

Sworn to or affirmed and signed before me on{date} __________________.

NOTARY PUBLIC or DEPUTY CLERK

{Print, type, or stamp commissioned name of notary or
deputy clerk.}

__Personally known
__ Produced identification
Type of identification produced ______________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the {choose only one} ( ) adoptee ( ) stepparent
This form was completed with the assistance of:
{name of individual}______________________________________________________________ ,
{name of business} _______________________________________________________________ ,
{address} _______________________________________________ ,
{city} ________________ ,{state} ,{zip code}_________ {telephone number} ______________ .

Florida Supreme Court Approved Family Law Form 12.981(a)(2), Stepparent Adoption: Consent of
Adoptee (03/15)
- 652 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.981(a)(3),
AFFIDAVIT OF NONPATERNITY (03/15)

When should this form be used?

This form should be used when a stepfather is adopting his wife’s minor child and the mother and father
of the minor child(ren) were never married and paternity has not been established by a valid
acknowledgment or court order. This Affidavit of Nonpaternity may be used instead of a consent form.
This Affidavit may be executed before the birth of the minor child. The person signing the affidavit
waives notice to all court proceedings after the date it is signed. After signing this affidavit, it may only
be withdrawn if the court finds the affidavit was obtained by fraud or duress.

This form should be typed or printed in black ink. This form must be signed before a notary public or
deputy clerk and two witnesses other than the notary or clerk. You should then file the original of this
form with the Joint Petition for Stepparent Adoption, Florida Supreme Court Approved Family Law
Form 12.981(b)(1).

IMPORTANT INFORMATION REGARDING E-FILING

The Florida Rules of Judicial Administration now require that petitions, pleadings, and documents be
filed electronically except in certain circumstances. Self-represented litigants may file petitions or other
pleadings electronically; however, they are not required to do so. If you choose to file your pleadings
or other documents electronically, you must do so in accordance with Florida Rule of Judicial
Administration 2.525, and you must follow the procedures of the judicial circuit in which you file. The
rules and procedures should be carefully read and followed.

Special Notes

Remember--a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.981(a)(3), Affidavit of Nonpaternity (03/15)
- 653 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR __ COUNTY, FLORIDA

Case No.:
Division:

IN THE MATTER OF THE ADOPTION OF

___________________________________________,
{use name to of the minor child(ren)}Adoptee(s)

AFFIDAVIT OF NONPATERNITY
I, {full legal name} , have personal knowledge of the facts
stated in this affidavit and certify that the following statements are true:

2. I have been told that {name} has a child. I do not wish to
and shall not establish or claim paternity for this child, whose name is ____________ and
whose date of birth is ______________.
3. The child referenced in this affidavit was not conceived or born while the birth mother was
married to me. I AM NOT MARRIED TO THE BIRTH MOTHER, nor do I intend to marry the birth mother.
4. The child has not been established to be my child in any court proceeding and I have not
adopted this child.
5. I have no interest in assuming the responsibilities of parenthood for this child. I have not
acknowledged and will not acknowledge in writing that I am the father of this child or will not institute
court proceedings to establish the child as mine.
5. I do not object to any decision or arrangements the birth mother makes regarding this child,
including adoption.
6. I understand my right to choose a person who does not have an employment, professional, or
personal relationship with the adoption entity or the prospective adoptive parents to be present
when this affidavit is executed and to sign it as a witness. The witness I selected is {full legal
name} .
7. I am executing this affidavit freely and voluntarily and I understand that it can only be
withdrawn if the court finds it was executed by fraud or duress.

I WAIVE NOTICE OF ANY AND ALL PROCEEDINGS TO TERMINATE PARENTAL RIGHTS OR FINALIZE AN
ADOPTION UNDER CHAPTER 63, FLORIDA STATUTES.

Florida Supreme Court Approved Family Law Form 12.981(a)(3), Affidavit of Nonpaternity (03/15)
- 654 -
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
affidavit and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.

Signature
Printed Name: _________________________________
Address: ______________________________________
City, State, Zip: _________________________________
Designated E-mail Address(es):____________________

Signature of Witness Signature of Witness
Printed Name: Printed Name:
Business Address: Business Address:
Home Address: Home Address:
Driver’s License or Driver’s License or
State ID Card No.: State ID Card No.:

STATE OF FLORIDA
COUNTY OF

Sworn to or affirmed and signed before me on {date} .

NOTARY PUBLIC or DEPUTY CLERK

[Print, type, or stamp commissioned name of notary or
deputy clerk.]
Personally known
Produced identification
Type of identification produced

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) parent or ( ) stepparent
This form was completed with the assistance of:
{name of individual}_________________________________________________________________ ,
{name of business} ___________________________________________________________________ ,
{address} ___________________________________________ ,
{city} ________________,{state} ____, {zip code}_________,{telephone number} .

Florida Supreme Court Approved Family Law Form 12.981(a)(3), Affidavit of Nonpaternity (03/15)
655
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.981(a)(4),
STEPPARENT ADOPTION: AFFIDAVIT OF DILIGENT SEARCH (03/15)

When should this form be used?

Use this form to obtain constructive service (also called service by publication) in a proceeding for
stepparent adoption, Joint Petition for Adoption by Stepparent, Florida Supreme Court Approved
Family Law Form 12.981(b)(1), when any required consent is unavailable because the address or
location of the person whose consent is required is not known and cannot be determined.

This form includes a checklist of places you must look for information on the location of the person
whose rights you seek to terminate. You do have to look in all of these places, and the court must
believe that you have made a very serious effort to get information about the person’s location and that
you have followed up on any information you received. Section 63.054, Florida Statutes, requires that in
each adoption a search of Florida’s Putative Father Registry must be conducted. You will need an order
from the judge to do this, which you can request by filing a Motion for Search of the Putative Father
Registry, Florida Supreme Court Approved Family Law Form 12.981(a)(6).

IMPORTANT INFORMATION REGARDING E-FILING

The Florida Rules of Judicial Administration now require that all petitions, pleadings, and documents be
filed electronically except in certain circumstances. Self-represented litigants may file petitions or other
pleadings or documents electronically; however, they are not required to do so. If you choose to file
your pleadings or documents electronically, you must do so in accordance with Florida Rule of Judicial
Administration 2.525, and you must follow the procedures of the judicial circuit in which you file. The
rules and procedures should be carefully read and followed.

Where can I look for more information?

Before proceeding, you should read General Information for Self-Represented Litigants found at the
beginning of these forms. For further information, see rule 12.070, Florida Family Law Rules of
Procedure and Rule 1.070, Florida Rules of Civil Procedure.

Special notes...

Instructions for Florida Supreme Court Approved Family Law Form 12.981(a)(4), Petition for Stepparent Adoption:
Affidavit of Diligent Search (03/15)
- 656 -
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.981(a)(4), Petition for Stepparent Adoption:
Affidavit of Diligent Search (03/15)
- 657 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR __ COUNTY, FLORIDA

Case No.:
Division:
IN THE MATTER OF THE ADOPTION OF

______________________________________________
{use name to be given to the minor child(ren)} Adoptee(s).

PETITION FOR STEPPARENT ADOPTION:
AFFIDAVIT OF DILIGENT SEARCH
I, {full legal name} , being sworn, certify that the
following information is true:

1. I am the child(ren)’s _____ mother _____ father.

2. The last known address of the child(ren)’s other parent {name} _____,
as of {date} , was:

Address City State Zip

Telephone No. ____________________ Fax No. ______________________________

His/her last known employment, as of {date} , was:

Name of Employer

Address City State Zip

Telephone No. ____________________ Fax No. ________________________

3. The other parent is over the age of 18.

4. The other parent’s current residence is not known and cannot be determined, although I have
made a diligent search and inquiry to locate him/her through the following:
You must search ALL of the following sources of information and state the results.
__United States Post Office inquiry through the Freedom of Information Act for the
person’s current address or any previous address.
Result of search: __________________
__Last known employment of the other parent, including name and address of employer.

Florida Supreme Court Approved Family Law Form 12.981(a)(4), Petition for Stepparent Adoption: Affidavit of
Diligent Search (03/15)
- 658 -
Result of search: __________________
__Regulatory agencies, including professional or occupational licensing, in the area where
the other parent last resided.
Result of search: __________________
__Names and addresses of relatives to the extent such can be reasonably obtained from
the petitioner or other sources, contacts with those relatives and inquiry as to the other
parent’s last known address. You are to follow up any leads of any addresses where the other
parent may have moved.
Result of search: ______________________________
___ Information about the other parent’s possible death and, if dead, the date and
location.
Result of search:_________________________________________________________
___Telephone listings in the area where the other parent last resided.
Result of search: ________________
___Law enforcement agencies in the area where the other parent last resided.
Result of search: _______________
___Highway Patrol records in the state where the other parent last resided.
Result of search: ________________
___Department of Corrections records in the state where the other parent last resided.
Result of search: _______________
___Hospitals in the last known area of the other parent’s residence.
Result of search: _______________
_ __Records of utility companies, which include water, sewer, cable TV, and electric in the
last known area of the other parent’s residence.
Result of search: _________________
___Records of the Armed Forces of the U.S. and their response as to whether or not there
is any information about the other parent. (See Florida Supreme Court Approved Family Law
Form 12.912(a), Memorandum for Certificate of Military Service.)
Result of search: __________________
___Records of the tax assessor’s and tax collector’s office in the area where the other
parent last resided.
Result of search: __________________
____ Search of one Internet databank locator service.
Result of search: __________________
___Title IV-D (child support enforcement) agency records in the state of the other parent’s
last known address.
Result of search: _________________________

{if applicable}:
_____ A search of the Putative Father Registry maintained by the Office of Vital Statistics of
the Department of Health has been requested, and if granted, the certificate from the State
Registrar will be filed in this action.

Florida Supreme Court Approved Family Law Form 12.981(a)(4), Petition for Stepparent Adoption: Affidavit of
Diligent Search (03/15)
- 659 -
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
affidavit and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.

Dated:
Signature of Petitioner

Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es): __________________
____________________________________________

STATE OF FLORIDA
COUNTY OF

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

[Print, type, or stamp commissioned name of notary
deputy clerk.]

__ Personally known
___ Produced identification
Type of identification produced

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the petitioner.
This form was completed with the assistance of:
{name of individual} _______________________________________________________________ ,
{name of business} ________________________________________________________________ ,
{address} _________________________________________________________________________ ,
{city} __________________, {state} _, {zip code}________, {telephone number}_______________ .

Florida Supreme Court Approved Family Law Form 12.981(a)(4), Petition for Stepparent Adoption: Affidavit of
Diligent Search (03/15)
- 660 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.981(a)(5),
INDIAN CHILD WELFARE ACT AFFIDAVIT (03/15)

When should this form be used?

This form should be used in cases involving stepparent adoption of a child. This affidavit is required.

IMPORTANT INFORMATION REGARDING E-FILING

The Florida Rules of Judicial Administration now require that all petitions, pleadings, and documents be
filed electronically except in certain circumstances. Self-represented litigants may file petitions or other
pleading or documents electronically; however, they are not required to do so. If you choose to file
your pleadings or other documents electronically, you must do so in accordance with Florida Rule of
Judicial Administration 2.525, and you must follow the procedures of the judicial circuit in which you file.
The rules and procedures should be carefully read and followed.

What should I do next?

A copy of this form must be mailed, e-mailed, or hand delivered to the other party in your case, if it is
not served on him or her with your initial papers.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

To serve and receive documents by e-mail, you must designate your e-mail addresses by using the
Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family Law Form
12.915, and you must provide your e-mail address on each form on which your signature appears.
Please CAREFULLY read the rules and instructions for: Certificate of Service (General), Florida Supreme

Instructions for Florida Supreme Court Approved Family Law Form 12.981(a)(5), Indian Child Welfare Act Affidavit
(03/15)
- 661 -
Court Approved Family Law Form 12.914; Designation of Current Mailing and E-mail Address, Florida
Supreme Court Approved Family Law Form 12.915; and Florida Rule of Judicial Administration 2.516.

Where can I look for more information?

Special notes...

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.981(a)(5), Indian Child Welfare Act Affidavit
(03/15)
- 662 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.: __________________________
Division: __________________________

IN THE MATTER OF THE ADOPTION OF

,
{use name to be given to the minor child(ren)} Adoptee(s).

INDIAN CHILD WELFARE ACT AFFIDAVIT
I, {full legal name}_______________________, being sworn, certify that the following statements are
true:
Upon information and belief the child __________ {name} subject to this proceeding:
{choose one only}
1. _is not an Indian child. The Indian Child Welfare Act does not apply to this proceeding.

2. __is an Indian child within the meaning of the Indian Child Welfare Act of 1978 (25 U.S.C. Section
1901 et seq.).

I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-
delivered to the person(s) listed below on {date} ___________________________.

Other party or his/her attorney:
Name:_____________________
Address:_________________________
City, State, Zip:_______________________
Fax Number: ____________________
Designated E-mail Address(es): _________

Dated: _____ _________________________________________
Signature of Party
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es):____________________

Florida Supreme Court Approved Family Law Form 12.981(a)(5), Indian Child Welfare Act Affidavit (03/15)
- 663 -
STATE OF FLORIDA
COUNTY OF

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

{Print, type, or stamp commissioned name of notary or clerk.}

__ Personally known
__ Produced identification
Type of identification produced _____________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent
This form was completed with the assistance of:
{name of individual} ____________________________________________________________________,
{name of business} _____________________________________________________________________,
{address} _____________________________________________ ,
{city} _________________,{state} _, {zip code}________, {telephone number} .

Florida Supreme Court Approved Family Law Form 12.981(a)(5), Indian Child Welfare Act Affidavit (03/15)
- 664 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.981(a)(6),
MOTION FOR SEARCH OF THE PUTATIVE FATHER REGISTRY (03/15)
When should this form be used?

This form should be used when a stepparent is adopting his or her spouse’s child. Section 63.054,
Florida Statutes, requires that a search of Florida’s Putative Father Registry be conducted in every
adoption proceeding. The Office of Vital Statistics of the Department of Health has an application
available called Florida Putative Father Registry - Application for Search which should be completed and
attached to this form. The Office of Vital Statistics is allowed to charge for searching the registry. You
may wish to contact that office in advance to find out what amount and method of payment will be
accepted.

This form should be typed or printed in black ink. The name to be given to the adoptee after the
adoption should be used in the heading of the petition. The stepparent is the petitioner, because he or
she is the one who is asking the court for legal action. You must have your signature witnessed by a
notary public or deputy clerk.

After completing this form, you should file the original with the clerk of the circuit court in the county
where you have filed the Joint Petition for Adoption by Stepparent, Florida Supreme Court Approved
Family Law Form 12.981(b)(1) and keep a copy for your records. These family law forms contain an
Order Granting Motion for Search of Putative Father Registry, Florida Supreme Court Approved Family
Law Form 12.981(a)(7), which the judge may use. You should check with the clerk, family law intake
staff or judicial assistant to see if you need to provide this form order to the judge with your motion. If
so, you should type or print the heading, including the circuit, county, case number, division, and the
child(ren)’s name, and leave the rest blank for the judge to complete.

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?

If the judge grants your motion, you will need to take the order, your completed application, and any fee
to the Office of Vital Statistics. That office will conduct the search and file the results with the clerk of
court. You may call the clerk’s office to determine when the results have been filed in order to set a

Instructions for Florida Supreme Court Approved Family Law Form 12.981(a)(6), Motion for Search of Putative
Father Registry (03/15)
- 665 -
final hearing.

Where can I look for more information?

Before proceeding, you should read General Information for Self-Represented Litigants found at the
beginning of these forms. See Chapter 63, Florida Statutes, and Florida Family Law Rule 12.200(a)(2) for
further information.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Special notes...

THIS ADOPTION MAY AFFECT THE ADOPTEE’S INHERITANCE.

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.981(a)(6), Motion for Search of Putative
Father Registry (03/15)
- 666 -
IN THE CIRCUIT COURT OF THE _____________________________ JUDICIAL CIRCUIT,
IN AND FOR ________________________ COUNTY, FLORIDA

Case No.: ____________________________
Division: ____________________________
IN THE MATTER OF THE ADOPTION OF

____________________________________,
{use name to be given to the minor child} Adoptee.

MOTION FOR SEARCH OF THE PUTATIVE FATHER REGISTRY

Petitioner, {full legal name} ________________________________, files this Motion for Search of the
Putative Father Registry, pursuant to Chapter 63, Florida Statutes, and states:

1. This is an action for adoption of a minor by the child’s stepparent, who is the Petitioner. .

2. Section 63.054, Florida Statutes, requires that in every adoption, a search of the Putative Father
Registry maintained by the Department of Health, Office of Vital Statistics be conducted.
Section 63.0541, Florida Statutes, makes information maintained by the Registry confidential
and exempt from public disclosure, except that it may be disclosed to adoption entities,
registrant unmarried biological fathers, and the court, upon issuance of a court order concerning
a petitioner acting pro se.

3. The Florida Putative Father Registry - Application for Search is completed and attached to this
Motion.

WHEREFORE, I request that this Court enter an Order Granting Motion for Search of the Putative Father
Registry.

Florida Supreme Court Approved Family Law Form 12.981(a)(6), Motion for Search of Putative Father Registry
(03/15)
- 667 -
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
motion and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.

Dated:____________________ ___________________________________________
Signature of Party

Printed Name:____________________________________
Address: ________________________________________
City, State, Zip:___________________________________
Telephone Number: _______________________________
Fax Number:
Designated E-mail Address(es):
_______________________________________________

STATE OF FLORIDA
COUNTY OF ___________________________

Sworn to or affirmed and signed before me on___________________by___________________.

______________________________________________
NOTARY PUBLIC or DEPUTY CLERK

______________________________________________
{Print, type, or stamp commissioned name of notary or clerk.}
_____ Personally known
_____ Produced identification
Type of identification produced ___________________________

Florida Supreme Court Approved Family Law Form 12.981(a)(6), Motion for Search of Putative Father Registry
(03/15)
- 668 -
{address} _________________________________________________________________________ ,
{city}______________,{state} ____, {zip code}__________, {telephone number}_________________ .

Florida Supreme Court Approved Family Law Form 12.981(a)(6), Motion for Search of Putative Father Registry
(03/15)
- 669 -
IN THE CIRCUIT COURT OF THE ________________JUDICIAL CIRCUIT,
IN AND FOR ____________________________COUNTY, FLORIDA

Case No.:____________________________
Division: ____________________________
IN THE MATTER OF THE ADOPTION OF

___________________ ,
{use name to be given to the minor child} Adoptee.

ORDER GRANTING MOTION FOR SEARCH OF
THE PUTATIVE FATHER REGISTRY

Upon consideration of Petitioner’s Motion for Search of the Putative Father Registry, this Court finds:

1. This is an action for adoption of a minor by the child’s stepparent, Petitioner, who is proceeding
pro se.

2. Section 63.054, Florida Statutes, requires that in every adoption, a search of the Putative Father
Registry maintained by the Department of Health, Office of Vital Statistics be conducted.
Section 63.0541, Florida Statutes, makes information maintained by the Registry confidential
and exempt, except that it may be disclosed to adoption entities, registrant unmarried biological
fathers, the birth mother, and the court, upon issuance of a court order concerning a petitioner
acting pro se.

NOW, THEREFORE, IT IS ORDERED THAT:

1. The Office of Vital Statistics, Department of Health shall conduct a search of the Putative Father
Registry upon receipt of a completed application and payment of any authorized fee.

2. The State Registrar shall issue a certificate indicating the results of such search which shall be
filed in this proceeding by transmitting the certificate to the clerk of court.

DONE and ORDERED on: ____________________in __________________________, Florida.

______________________________________

Florida Supreme Court Approved Family Law Form 12.981(a)(7), Order Granting Motion for Search of Putative
Father Registry (03/15)
- 670 -
Circuit Judge

I certify that a copy of the {name of document(s)}_____________________________________________
was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the parties and to any other
persons or entities listed below on {date} ___________________________________________.

__________________________________________
By: Clerk of Court, Designee, or Judicial Assistant

Petitioner (or his or her attorney)
Other: ______________________
State Registrar, Office of Vital Statistics

Florida Supreme Court Approved Family Law Form 12.981(a)(7), Order Granting Motion for Search of Putative
Father Registry (03/15)
- 671 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.981(b)(1),
JOINT PETITION FOR ADOPTION BY STEPPARENT (03/15)
When should this form be used?

This form should be used when a stepparent is adopting his or her spouse’s child. Both the stepparent
and his or her spouse must sign this petition. You must attach all necessary consents or
acknowledgments that apply to your case, as listed under the Special Notes section below. Florida
Statutes require that consent to adoption be obtained from:
 The mother of the minor.
 The father of the minor if:
1. The minor was conceived or born while the father was married to the mother;
2. The minor is his child by adoption;
3. The minor has been established by a court proceeding to be his child;
4. He has filed an affidavit of paternity pursuant to section 382.013(2)(c) Florida Statutes; or
5. In the case of an unmarried biological father, he has acknowledged in writing, signed in the
presence of a competent witness, that he is the father of the minor, has filed such
acknowledgment with the Office of Vital Statistics of the Department of Health within the
required timeframes, and has complied with the requirements of section 63.062(2), Florida
Statutes.

Determining whether someone’s consent is required, or when consent may not be required is a
complicated issue and you may wish to consult an attorney. For more information about consenting to
adoption, you should refer to Chapter 63, Florida Statutes, and sections 63.062-63.082 in particular.

This form should be typed or printed in black ink. The name to be given to the child(ren) after the
adoption should be used in the heading of the petition. The stepparent is the petitioner, because he or
she is the one who is asking the court for legal action. After completing this form, you and your spouse
must sign it before a notary public or deputy clerk. You should then file the original and 1 copy with the
clerk of the circuit court in the county where the minor resides unless the court changes the venue.

IMPORTANT INFORMATION REGARDING E-FILING

The Florida Rules of Judicial Administration now require that all petitions, pleadings, and documents be
filed electronically except in certain circumstances. Self-represented litigants may file petitions or other
pleadings or documents electronically; however, they are not required to do so. If you choose to file
your pleadings or documents electronically, you must do so in accordance with Florida Rule of Judicial
Administration 2.525, and you must follow the procedures of the judicial circuit in which you file. The
rules and procedures should be carefully read and followed.

What should I do next?

Instructions for Florida Supreme Court Approved Family Law Form 12.981(b)(1), Joint Petition for Adoption by
Stepparent (03/15)
- 672 -
For your case to proceed, you must have the written consent of the other birth parent and the child, if
applicable. The court may choose not to require consent to an adoption in some circumstances. For
more information about situations where consent may not be required, see section 63.064, Florida
Statutes. If you are attempting to proceed without the consent of the other birth parent, you may wish
to consult with an attorney. Section 63.054, Florida Statutes, requires that in each adoption proceeding,
the Florida Putative Father Registry be searched. You will need an order from the judge to do this,
which you can request by filing a Motion for Search of the Putative Father Registry, Florida Supreme
Court Approved Family Law Form 12.981(a)(6).

When you have filed all of the required forms and met the requirements as outlined above, you are
ready to set a hearing on your petition. You should check with the clerk of court, family law intake staff
or the judicial assistant to set a final hearing. If all persons required to consent have consented and the
consents/affidavits of nonpaternity have been filed with the court, the hearing may be held
immediately. If not, notice of the hearing must be given as provided by the Rules of Civil Procedure. See
Form 1.902, Florida Rules of Civil Procedure. If you know where the other birth parent lives, you should
use personal service. If you absolutely do not know where he or she lives, you may use constructive
service. In order to use constructive service you will need to complete and submit to the court
Stepparent Adoption: Affidavit of Diligent Search, Florida Supreme Court Approved Family Law Form
12.981(a)(4). For more information about personal and constructive service, you should refer to the
“General Instructions for Self-Represented Litigants” found at the beginning of these forms and the
instructions to Florida Family Law Rules of Procedure Forms 12.910(a) and 12.913(b) and Florida
Supreme Court Approved Family Law Form 12.913(a). However, the law regarding constructive service
is very complex and you may wish to consult an attorney regarding that issue.

Where can I look for more information?

Before proceeding, you should read “General Information for Self-Represented Litigants” found at the
beginning of these forms. See Chapter 63, Florida Statutes, and Florida Family Law Rule 12.200(a)(2) for
further information.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

To serve and receive documents by e-mail, you must designate your e-mail addresses by using the
Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family Law Form

Instructions for Florida Supreme Court Approved Family Law Form 12.981(b)(1), Joint Petition for Adoption by
Stepparent (03/15)
- 673 -
12.915, and you must provide your e-mail address on each form on which your signature appears.
Please CAREFULLY read the rules and instructions for: Certificate of Service (General), Florida Supreme
Court Approved Family Law Form 12.914; Designation of Current Mailing and E-mail Address, Florida
Supreme Court Approved Family Law Form 12.915; and Florida Rule of Judicial Administration 2.516.

Special notes...

With this petition you must file the following:
 Consent form executed by the birth parent, Stepparent Adoption: Consent and Waiver by
Parent, Florida Supreme Court Approved Family Law Form 12.981(a)(1) or Stepparent Adoption:
Affidavit of Nonpaternity, Florida Supreme Court Approved Family Law Form 12.981(a)(3).
 If any person whose consent is required is deceased, a certified copy of the death certificate
must be attached to this Petition.
 Consent form executed by the minor child(ren), if the child(ren) is/are over 12 years of age,
Stepparent Adoption: Consent of Adoptee, Florida Supreme Court Approved Family Law Form
12.981(a)(2). The court can excuse filing of this form under certain circumstances.
 Certified copy of the child(ren)’s birth certificate.
 Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida Supreme
Court Approved Family Law Form 12.902(d).
 If applicable, Stepparent Adoption: Motion for Search of the Putative Father Registry, Florida
Supreme Court Approved Family Law Form 12.981(a)(6).

These family law forms contain a Final Judgment of Stepparent Adoption, Florida Supreme Court
Approved Family Law Form 12.981(b)(2), which the judge may use. You should check with the clerk,
family law intake staff, or judicial assistant to see if you need to bring a final judgment form with you to
the hearing. If so, you should type or print the heading, including the circuit, county case number,
division, and the child(ren)’s names, and leave the rest blank for the judge to complete at your hearing.
You should decide how many certified copies of the final judgment you will need and be prepared to
obtain them after the hearing. There is a charge for certified copies, and the clerk can tell you how
much. The file will be sealed after the final hearing, and then it will take an order from a judge to open
the file and obtain a copy of the final judgment.

AN ADOPTIVE STEPPARENT WILL CONTINUE TO HAVE PARENTAL RIGHTS, INCLUDING CUSTODY AND
TIME-SHARING, WHERE APPROPRIATE, IN THE EVENT OF A LATER DISSOLUTION OF MARRIAGE, AND
MAY BE LIABLE FOR CHILD SUPPORT IN THE EVENT OF A LATER DISSOLUTION OF MARRIAGE. YOU
COULD BE LIABLE IN LITIGATION FOR THE ACTIONS OF THE ADOPTEE(S). THIS ADOPTION MAY ALSO
AFFECT THE ADOPTEE’S INHERITANCE.

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.981(b)(1), Joint Petition for Adoption by
Stepparent (03/15)
674
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:

IN THE MATTER OF THE ADOPTION OF

________________________________________,
{use name to be given to child(ren)} Adoptee(s).

JOINT PETITION FOR ADOPTION BY STEPPARENT

Petitioner, {full legal name} _____________________________________________being sworn,
joined by the above-named child(ren)’s _____ mother _____ father, {full legal name}
________________________, being sworn, files this joint petition for adoption of the above-named
minor child(ren), under chapter 63, Florida Statutes.

1. This is an action for adoption of a minor child(ren) by his or her (their) stepparent.

2. I desire to adopt the following child(ren):
Name to be given to child(ren) Birth date Birthplace
a. __________________________________________________________________
b. _____________________________________________________________________
c. ____________________________________________________________________
d. _____________________________________________________________________
e. _____________________________________________________________________
f. _____________________________________________________________________
A certified copy of the birth certificate(s) is/are attached.

3. The child(ren) has (have) resided with me since {date} __________________________________.
I wish to adopt the child(ren) because I would like to legally establish the parent-child
relationship already existing between the child(ren) and me. Since the above date, I have been
able to provide adequately for the material needs of the child(ren) and am able to continue
doing so in the future, as well as to provide for the child(ren)’s mental and emotional well-being.
Other reasons I wish to adopt the children are: _______________________________________
______________________________________________________________________________
______________________________________________________________________________

4. I am _________ years old, and have resided at {street address}, __________________________
{city} ____________________ {county} _______________ {state} __________ for ______ years.

5. I married the _____ father or _____ mother of the child(ren) on {date}_____________________,

Florida Supreme Court Approved Family Law Form 12.981(b)(1), Joint Petition for Adoption by Stepparent
(03/15)
- 675 -
in {city} ____________________, {county}_________________, {state} ____________________.
The following are the dates and places of my dissolutions of marriage, if any:
Date Place
a.
b.

6. A completed Uniform Child Custody Jurisdiction and Enforcement Act Affidavit (UCCJEA),
Florida Supreme Court Approved Family Law Form 12.902(d), is filed with this petition.

7. A description and estimate of the value of any property of the adoptee(s) is as follows:

8. Consent by the adoptee(s):
_____ is attached for: Name(s)
_____is not required because the adoptee(s) is/are not 12 years of age: Name(s)
_____ was excused by the court for: Name(s)

9. The following person(s) is/are required to consent and the consent form or affidavit of
nonpaternity is/are attached ______________________________________________________

10. The following person(s) whose consent is required has not consented. The facts/circumstances
that excuse the lack of consent and would justify termination of this person’s parental rights
are:
Name Address Facts/circumstances
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

11. A copy of this Petition was served on all known persons whose consent is required but did not
waive notice, as well as on all persons whose consent is required but did not provide consent.
Proof of service is attached.

{Indicate if applicable}:
_____ A search of the Putative Father Registry maintained by the Office of Vital Statistics of the
Department of Health has been requested, and if granted, the certificate from the State
Registrar will be filed in this action.

WHEREFORE, I request that this Court terminate the parental rights of ___________________________,
{name of parent whose rights are sought to be terminated}, enter a Final Judgment of Adoption of the

Florida Supreme Court Approved Family Law Form 12.981(b)(1), Joint Petition for Adoption by Stepparent
(03/15)
- 676 -
Minor Child(ren) by Petitioner Stepparent and, as requested, change the name of the adoptee(s).

Florida Supreme Court Approved Family Law Form 12.981(b)(1), Joint Petition for Adoption by Stepparent
(03/15)
- 677 -
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
petition and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.

Dated: __________________________ _____________________________________________
Signature of Stepparent

Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es):
_____________________________________________

STATE OF FLORIDA
COUNTY OF_________________________

Sworn to or affirmed and signed before me on ___________________by

____________________________________________
NOTARY PUBLIC or DEPUTY CLERK

_____________________________________________
[Print, type, or stamp commissioned name of notary or
deputy clerk.]
_____ Personally known
_____ Produced identification
Type of identification produced _______________________________

Florida Supreme Court Approved Family Law Form 12.981(b)(1), Joint Petition for Adoption by Stepparent
(03/15)
- 678 -
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
petition and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.

Dated:__________________________ _____________________________________________
Signature of _____ Mother _____Father
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es):____________________
_____________________________________________

STATE OF FLORIDA
COUNTY OF ______________________

Sworn to or affirmed and signed before me on ____________________ by .

NOTARY PUBLIC or DEPUTY CLERK

[Print, type, or stamp commissioned name of notary or
deputy clerk.]
_____ Personally known
_____ Produced identification
Type of identification produced _______________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: ( ) parent ( ) stepparent ( ) both.
This form was prepared with the assistance of:
{name of individual} ______________________________________________________________ ,
{name of business} ________________________________________________________________ ,
{address} __________________________________________________________________________ ,
{city} __________________,{state}_______, {zip code}_________, {telephone number} ______________.

Florida Supreme Court Approved Family Law Form 12.981(b)(1), Joint Petition for Adoption by Stepparent
(03/15)
- 679 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
IN THE MATTER OF THE ADOPTION OF

________________________________________,
{use name to be given to child(ren)} Adoptee(s).

FINAL JUDGMENT OF STEPPARENT ADOPTION

Upon consideration of the Joint Petition for Adoption by Stepparent and the evidence presented, the
Court finds that:

1. The Court has subject matter jurisdiction over the Joint Petition for Adoption by Stepparent.

2. The Court has jurisdiction over the minor child(ren) subject to the Joint Petition for Adoption by
Stepparent.

3. Petitioner desires the permanent responsibility of a parent in this adoption.

4. There is no pending litigation regarding the child(ren) in Florida or in any other state, nor is
there any other person not a party to these proceedings who has or claims to have physical
custody or rights to the minor child(ren).

5. The consent of the birth _____mother _____ father who is not married to Petitioner is:
{Choose only one}
_____ Attached to the petition
_____ Not required because he or she is deceased. A certified copy of the death certificate is
attached.
_____ Waived because:
[Indicate all that apply]
_____ The parent has deserted the child without means of identification or has abandoned the
child.
_____ The parent’s rights have been terminated by a court of competent jurisdiction.
_____ The parent has been declared incompetent and restoration of competency is medically
improbable.
_____ The legal guardian or lawful custodian of the adoptee(s), other than the birth parent,
who has failed to respond in writing to a request for consent for a period of 60 days or
the Court has examined the written reasons for withholding consent and has found the
withholding of consent to be unreasonable.
_____ Other: ____________________________________________________________.

Florida Supreme Court Approved Family Law Form 12.981(b)(2), Final Judgment of Stepparent Adoption
(03/15)
- 680 -
6. The best interests of the child(ren) will be promoted by this adoption.

7. The minor child(ren) is (are) suitable for adoption by Petitioner.

NOW, THEREFORE, IT IS ORDERED that:

1. The minor child(ren) subject to the Petition is (are) declared to be the legal child(ren) of
Petitioner,_______________________________________________________ {name}

2. The minor child(ren) shall be the child(ren) and legal heir(s) at law of Petitioner,
_______________________________________________________________, {name}
and shall be entitled to all rights and privileges, and subject to all obligations, of
child(ren) born of Petitioner.

3. All legal relations between the adoptee(s) and the parent whose rights are being terminated and
between the adoptee(s) and the relatives of that parent are terminated by this adoption, as are
all parental rights and responsibilities of that birth parent.

4. This Final Judgment of Adoption creates a relationship between the adoptee(s) and Petitioner
and all relatives of Petitioner that would have existed if the adoptee(s) was (were) a blood
descendant of the Petitioner, born within wedlock, entitled to all rights and privileges thereof,
and subject to all obligations of a child being born to Petitioner.

5. The minor child(ren) shall hereafter be known as {full legal name(s)}:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

DONE AND ORDERED at _____________________________, Florida on .

CIRCUIT JUDGE

I certify that a copy of {name of document(s)} ____________________________________________was
( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the parties and any persons
or entities listed below on {date} _________________________________.

_____________________________________________
By: Clerk of Court, Designee, or Judicial Assistant

Florida Supreme Court Approved Family Law Form 12.981(b)(2), Final Judgment of Stepparent Adoption
(03/15)
- 681 -
Petitioners (or their attorney)
Other: ____________________________

Florida Supreme Court Approved Family Law Form 12.981(b)(2), Final Judgment of Stepparent Adoption
(03/15)
- 682 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.981(c)(1),
PETITION FOR ADOPTION OF ADULT BY STEPPARENT (03/15)
When should this form be used?

This form should be used when a stepparent is adopting his or her spouse’s adult child. You must obtain
the written consent of the adult child to be adopted, as well as the written consent of his or her spouse
(if married).

After completing this form, you should file the original with the clerk of the circuit court in the county
where either you or the adoptee live and keep a copy for your records.

IMPORTANT INFORMATION REGARDING E-FILING

The Florida Rules of Judicial Administration now require that petitions, pleadings, and documents be
filed electronically except in certain circumstances. Self-represented litigants may file a petition or
other pleadings electronically; however, they are not required to do so. If you choose to file your
petition, or other pleading or document electronically, you must do so in accordance with Florida Rule of
Judicial Administration 2.525, and you must follow the procedures of the judicial circuit in which you file.
The rules and procedures should be carefully read and followed.

What should I do next?

For your case to proceed, you must have the written consent of the adoptee, and his or her spouse if
married. Consent of the birth parent is not required, but written notice of the final hearing on the
adoption must be provided to the parents, if any, or proof of service of process must be filed showing
notice has been served on the parents. If you know where they live, you must use personal service. If
you absolutely do not know where they live, you may use constructive service. For more information
about personal and constructive service, you should refer the General Instructions for Self-Represented
Litigants found at the beginning of these forms and the instructions to Florida Family Law Rules of
Procedure Forms 12.910(a) and 12.913(b) and Florida Supreme Court Approved Family Law Form
12.913(a). However, the law regarding constructive service is very complex and you may wish to consult
an attorney regarding that issue.

When you have filed all of the required forms and met the requirements for consent as outlined above,
you are ready to set a hearing on your petition. You should check with the clerk of court, family law

Instructions for Florida Supreme Court Approved Family Law Form 12.981(c)(1), Petition for Adoption of Adult by
Stepparent (03/15)
- 683 -
intake staff, or judicial assistant to set a final hearing, and notify the other party(ies) using a Notice of
Hearing (General), Florida Supreme Court Approved Family Law Form 12.923, or other appropriate
notice of hearing form.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Where can I look for more information?

With this petition you must file the following forms:

Stepparent Adoption: Consent of Adoptee, Florida Supreme Court Approved Family Law Form
12.981(a)(2)

Stepparent Adoption: Consent of Adult Adoptee’s Spouse, Florida Supreme Court Approved Family Law
Form 12.981(c)(2), if the adoptee is married

THIS ADOPTION MAY AFFECT THE ADOPTEE’S INHERITANCE.

Instructions for Florida Supreme Court Approved Family Law Form 12.981(c)(1), Petition for Adoption of Adult by
Stepparent (03/15)
- 684 -
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
IN THE MATTER OF THE ADOPTION OF

_________,
{use name to be given to adult} Adoptee.

PETITION FOR ADOPTION OF ADULT BY STEPPARENT

Petitioner, {full legal name} , files this petition for
adoption of the above-named adult, pursuant to Chapter 63, Florida Statutes, and states:

1. This is an action for adoption of an adult by the adult’s stepparent, Petitioner.

2. I desire to adopt {adult’s full legal name} ,
who was born on {date} , at {city, county, and state}
______________________________________________________________________________.

3. I desire to adopt the adult because:

4. I am years old, and I have resided at {address} ,
____________________________, Florida for years.

5. The adoptee’s name shall be:

6. The adoptee’s birth parents are:
______________________________________________________________________________
Father’s Name Birth date

Florida Supreme Court Approved Family Law Form 12.981(c)(1), Petition for Adoption of Adult by Stepparent
(03/15)
- 685 -
Address
________________________________________________________________________
Mother’s Name Birth date

Address

7. Notice. Notice to the birth parents was made by:

8. Consent.
{Indicate all that apply}

a. _____ The consent of the adoptee is attached.
b. _____ The adoptee is married to {full legal name of adoptee=s spouse} _________
_____________________________________, and the consent of the spouse is attached.
c. _____ The adoptee is not married.

9. Written notice of this final hearing was provided to the parents or proof of service of process
showing notice has been served on the parents is attached.

WHEREFORE, I request that this Court enter a Final Judgment of Adoption of the Adult by Petitioner
Stepparent and change the name of the adoptee.

Sworn to or affirmed and signed before me on by .

Florida Supreme Court Approved Family Law Form 12.981(c)(1), Petition for Adoption of Adult by Stepparent
(03/15)
- 686 -
NOTARY PUBLIC or DEPUTY CLERK

[Print, type, or stamp commissioned name of notary or
clerk.]
__ Personally known
__ Produced identification
Type of identification produced

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the petitioner.
This form was completed with the assistance of:
{name of individual}_______________________________________________________________ ,
{name of business} _________________________________________________________________ ,
{address} __________________________________________ ,
{city} _____________,{state} ______, {zip code}____________, {telephone number} _____________ .

Florida Supreme Court Approved Family Law Form 12.981(c)(1), Petition for Adoption of Adult by Stepparent
(03/15)
- 687 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.981(c)(2),
STEPPARENT ADOPTION: CONSENT OF ADULT ADOPTEE’S SPOUSE
(03/15)

When should this form be used?

This form must be completed by the spouse of an adult who is being adopted.

This form should be typed or printed in black ink. After completing this form, the spouse of the adoptee
should sign the form before a notary public or deputy clerk. You should file the original with the clerk of
the circuit court in the county where the petition for adoption of an adult was filed and keep a copy for
your records.

IMPORTANT INFORMATION REGARDING E-FILING

The Florida Rules of Judicial Administration now require that all petitions, pleadings, and documents be
filed electronically except in certain circumstances. Self-represented litigants may file petitions or other
pleadings or documents electronically; however, they are not required to do so. If you choose to file
your pleading or other document electronically, you must do so in accordance with Florida Rule of
Judicial Administration 2.525, and you must follow the procedures of the judicial circuit in which you file.
The rules and procedures should be carefully read and followed.

Special notes...

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.981(c)(2), Stepparent Adoption: Consent of
Adult Adoptee’s Spouse (03/15)
- 688 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.: _________________________
Division: _________________________
IN RE: THE ADOPTION OF

________________________ ,
{use name to be given to adult} Adoptee(s).

STEPPARENT ADOPTION: CONSENT OF ADULT ADOPTEE’S SPOUSE

1. I, {full legal name} , am the _____ wife _____ husband of
{full legal name} __________, who Petitioner,
{full legal name} ____ wishes to adopt.
2. I consent to the adoption of my spouse by Petitioner.
3. I understand my right to choose a person who does not have an employment, professional, or
personal relationship with the adoption entity or the prospective adoptive parents to be present
when this affidavit is executed and to sign it as a witness. The witness I selected is:
{full legal name}_______________________________________________________.
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
consent and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.
Dated:
Signature of Spouse
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es):____________________

___________________________________ ______________________________________________
Signature of Witness Signature of Witness
Printed Name: ________________________ Printed Name:
Business Address:_____________________ Business Address:
Home Address: _______________________ Home Address:

Florida Supreme Court Approved Family Law Form 12.981(c)(2), Stepparent Adoption: Consent of Adult Adoptee’s
Spouse (03/15)
- 689 -
Driver’s License or Driver’s License or
State ID Card No.:_____________________ State ID Card No.:

STATE OF FLORIDA
COUNTY OF

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

{Print, type, or stamp commissioned name of notary or
deputy clerk.}

__ Personally known
___ Produced identification
Type of identification produced

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the ( ) stepparent ( ) adult adoptee’s spouse.
This form was completed with the assistance of:
{name of individual} ____________________________________________________________________,
{name of business} _____________________________________________________________________,
{address} _____________________________________________,
{city} _________________,{state} __, {zip code}___________{telephone number} .

Florida Supreme Court Approved Family Law Form 12.981(c)(2), Stepparent Adoption: Consent of Adult Adoptee’s
Spouse (03/15)
- 690 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.981(d)(1),
PETITION FOR ADOPTION INFORMATION (03/15)

When should this form be used?

This form is used to request release of relevant medical or social information on an adoptee. You cannot
use this form to find out the identity of birth parent(s).

IMPORTANT INFORMATION REGARDING E-FILING

Special notes...

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.981(d)(1), Petition for Adoption Information
(03/15)
- 691 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
IN RE: THE ADOPTION OF

____________________________________,
Adoptee(s).

PETITION FOR ADOPTION INFORMATION
1. I, {full legal name} , am interested in this matter
as:
{choose one only}
_____adult adoptee (over 18).
_____adoptive parent.
_____adult birth sibling.
_____other: {specify} .

2. The adoptee(s), {name(s)}
was (were) born on {date} .

3. I request nonidentifying information as to family medical history and social history of the
adoptee(s) as follows:
{indicate all that apply}
__If available, to be furnished to adoptive parents before finalization of the adoption.

__If available, to be furnished to adoptee upon request after adoptee reaches majority.

4. The reason I am requesting disclosure of this information is:

Dated:
Signature of Petitioner
Printed Name:
Address:
City, State, Zip:
Telephone Number:

Florida Supreme Court Approved Family Law Form 12.981(d)(1), Petition for Adoption Information (03/15)
- 692 -
Fax Number:
Designated E-mail Address(es): ____________________

STATE OF FLORIDA
COUNTY OF

Sworn to or affirmed and signed before me on by:

NOTARY PUBLIC or DEPUTY CLERK

{Print, type, or stamp commissioned name of notary or
deputy clerk.}
__Personally known
__Produced identification
Type of identification produced

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) adult adoptee
( ) adoptive parent ( ) adult birth sibling ( ) other {specify}______________________________ .
This form was completed with the assistance of:
{name of individual} ____________________________________________________________________,
{name of business} _____________________________________________________________________,
{address} _____________________________________________ ,
{city} _______________,{state} , {zip code} __________, {telephone number} __________.

Florida Supreme Court Approved Family Law Form 12.981(d)(1), Petition for Adoption Information (03/15)
- 693 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
IN RE: THE ADOPTION OF

___________________________________,
Adoptee(s).

ORDER RELEASING ADOPTION INFORMATION
This case came before the Court upon the Petition for Adoption Information, and the Court being fully
advised in the premises, it is ORDERED:

1. _____The Petitioner shall receive
___ a. nonidentifying information as to:
___ b. identifying information as to: .
___ c. all records relating to the adoption proceedings.

2. _____ The petition is denied in whole or in part because: ____________________________________
_________________________________________________________________________ .

DONE and ORDERED on _________ in _________________________________, Florida.

CIRCUIT JUDGE

I certify that a copy of the {name of document(s)} ____________________________________________
was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the parties and to any other
persons or entities listed below on {date} __________________________________________.

_________________________________________
By: Clerk of Court, Designee, or Judicial Assistant
Petitioner (or his or her attorney)
Respondent (or his or her attorney)
Other:
__________________

Florida Supreme Court Approved Family Law Form 12.981(d)(2), Order Releasing Adoption Information (03/15)
- 694 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.982(a)
PETITION FOR CHANGE OF NAME (ADULT) (03/15)

When should this form be used?

This form should be used when an adult wants the court to change his or her name. This form is not to
be used in connection with a dissolution of marriage or for adoption of child(ren). If you want a change
of name because of a dissolution of marriage or adoption of child(ren) that is not yet final, the change
of name should be requested as part of that case.

IMPORTANT INFORMATION REGARDING E-FILING

What should I do next?

Unless you are seeking to restore a former name, you must have fingerprints submitted for a state
and national criminal records check. The fingerprints must be taken in a manner approved by the
Department of Law Enforcement and must be submitted to the Department for a state and national
criminal records check. You may not request a hearing on the petition until the clerk of court has
received the results of your criminal history records check. The clerk of court can instruct you on the
process for having the fingerprints taken and submitted, including information on law enforcement
agencies or service providers authorized to submit fingerprints electronically to the Department of Law
Enforcement. The process may take several weeks and you will have to pay for the cost of processing
the fingerprints and conducting the state and national criminal history records check.

Next, you must obtain a hearing date for the court to consider your request. If you are seeking to
restore a former name, a hearing on the petition MAY be held immediately after the petition is filed.
The final hearing on any other petition for a name change may be held immediately after the clerk of
court receives the results of your criminal history records check. You should ask the clerk of court, family
law intake staff, or judicial assistant about the local procedure for setting a hearing. You may be

Instructions for Florida Supreme Court Approved Family Law Form 12.982(a), Petition for Change of Name (Adult)
(03/15)
- 695 -
required to attend the final hearing. Included in these forms is a Final Judgment of Change of Name
(Adult), Florida Supreme Court Approved Family Law Form 12.982(b), which the judge may use. You
should check with the clerk, family law intake staff, or judicial assistant, to see if you need to bring a
final judgment form with you. If so, you should type or print the heading, including the circuit, county,
case number, division, and the parties’ names, and leave the rest blank for the judge to complete at
your hearing or trial.

If the judge grants your petition, he or she will sign this order. This officially changes your name. The
clerk can provide you with certified copies of the signed order. There will be charges for the certified
copies, and the clerk can tell you the amount of the charges.
Where can I look for more information?

Before proceeding, you should read General Information for Self-Represented Litigants found at the
beginning of these forms. For further information, see Section 68.07, Florida Statutes.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Special notes...

The heading of the form calls for the name of the petitioner. Your current legal name should be used,
as you are the one who is asking the court for relief. The judicial circuit, case number, and division may
be obtained from the clerk of court’s office when you file the petition.

It may be helpful to compile a list of all of the people and/or places that will need a copy of your final
judgment. This list may include the driver’s license office, social security office, banks, schools, etc. A

Instructions for Florida Supreme Court Approved Family Law Form 12.982(a), Petition for Change of Name (Adult)
(03/15)
- 696 -
list will help you know how many copies of your order you should get from the clerk of court after your
hearing.

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.982(a), Petition for Change of Name (Adult)
(03/15)
- 697 -
IN THE CIRCUIT COURT OF THE _________JUDICIAL CIRCUIT,
IN AND FOR______________________COUNTY, FLORIDA

Case No.: ________________________
Division: _________________________

_________________________________,
Petitioner.

PETITION FOR CHANGE OF NAME (ADULT)

I, {full legal name} _________________________________, being sworn, certify that the following
information is true:
1. My complete present name is: ________________________________________________________.
I request that my name be changed to: _________________________________________________.

2. I live in _________________ County, Florida, at {street address} _____________________________
_______________________________________________________________________________ .

3. I was born on {date}________________, in {city} _____________________, {county} __________,
{state} ___________, {country} _________________.

4. My father’s full legal name : __________________________________________________________ .
My mother’s full legal name: _________________________________________________________ .
My mother’s maiden name: ___________________________________________________________.

5. I have lived in the following places since birth:
Dates (to/from) Address
_______/_________ ____________________________________________________
_______/_________ ____________________________________________________
_______/_________ ____________________________________________________
_______/_________ ____________________________________________________
(___ Please indicate here if you are continuing these facts on an attached page.)

6. Family
{Indicate all that apply}
a. _____ I am not married.
b. _____ I am married. My spouse’s full legal name is: _____________________________________
c. _____ I do not have child(ren).
d. _____ The name(s), age(s), and address(es) of my child(ren) are as follows (all children, including

Florida Supreme Court Approved Family Law Form 12.982(a), Petition for Change of Name (Adult) (03/15)
- 698 -
those over 18, must be listed):
Name {last, first, middle initial} Age Address, City, State
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

(______Please indicate here if you are continuing these facts on an attached page.)

7. Former names
{Indicate all that apply}
__My name has never been changed by a court.
__My name previously was changed by court order from
to on {date} ________________________ ,
by {court, city, and state} .
A copy of the court order is attached.

__My name previously was changed by marriage from _______________________________
to on {date} ,
in {city, county, and state} .
A copy of the marriage certificate is attached.

__I have never been known or called by any other name.
__I have been known or called by the following other name(s):
{list name(s) and explain where you were known or called by such name(s)}
___________________________________________________________________________
___________________________________________________________________________ .

8. Occupation
My occupation is: .
I am employed at: {company and address}
.
During the past 5 years, I have had the following jobs:

Dates (to/from) Employer and employer’s address
_______/_______ __________________________________________________________
_______/_______ __________________________________________________________
_______/_______ __________________________________________________________
_______/_______ __________________________________________________________
_______/_______ __________________________________________________________
(_______Please indicate here if you are continuing these facts on an attached page.)
9. Business

Florida Supreme Court Approved Family Law Form 12.982(a), Petition for Change of Name (Adult) (03/15)
- 699 -
{Choose one only}
__ I do not own and operate a business.
__ I own and operate a business. The name of the business is: .
The street address is: .
My position with the business is: .
I have been involved with the business since: {date} .

10. Profession
{Choose one only}
__I am not in a profession.
__I am in a profession. My profession is: .
I have practiced this profession:
Dates (to/from) Place and address
_______/_______ __________________________________________________________
_______/_______ __________________________________________________________
_______/_______ __________________________________________________________
_______/_______ __________________________________________________________
_______/_______ __________________________________________________________
( _____ Please indicate here if you are continuing these facts on an attached page.)

11. Education
I have graduated from the following school(s):
Degree Date of
Received Graduation School
_________ _____________ __________________________________________________
_________ _____________ __________________________________________________
_________ _____________ __________________________________________________
(________ Please indicate here if you are continuing these facts on an attached page.)

12. Criminal History
{Choose one only}
_ I have never been arrested for or charged with, pled guilty or nolo contendere to, or been
found to have committed a criminal offense, regardless of adjudication.
_ I have a criminal history. In the past I have been arrested for or charged with, pled guilty or
nolo contendere to, or been found to have committed a criminal offense, regardless of adjudication.
The details of my criminal history are:

Date City/State Event (arrest, charge, plea, or adjudication)

( _______ Please indicate here if you are continuing these facts on an attached page.)

13. Bankruptcy

Florida Supreme Court Approved Family Law Form 12.982(a), Petition for Change of Name (Adult) (03/15)
- 700 -
{Choose one only}
I have never been adjudicated bankrupt.
I was adjudicated bankrupt on {date} , in {city} ,
{county} , {state} .
(___Please indicate here if you have filed additional bankruptcies, and explain on an attached page.)
14. Creditor(s)’ Judgments
{Choose one only}
__I have never had a money judgment entered against me by a creditor.
__The following creditor(s)’ money judgment(s) have been entered against me:
Date Amount Creditor Court entering judgment and case number if Paid {date}
______ _________ _________ _______________________________________________
______ _________ _________ _______________________________________________
______ _________ _________ _______________________________________________
______ _________ _________ _______________________________________________
(_______ Please indicate here if these facts are continued on an attached page.)

15. Fingerprints and Criminal History Records Check
Unless I am seeking to restore a former name, a copy of my fingerprints has been taken in a manner
approved by the Department of Law Enforcement and submitted for a state and national criminal
history records check. I understand that I cannot request a hearing on my Petition until the Clerk
of Court receives the results of the criminal history records check.

16. I have no ulterior or illegal purpose for filing this petition, and granting it will not in any manner
invade the property rights of others, whether partnership, patent, good will, privacy, trademark, or
otherwise.

17. My civil rights have never been suspended, or, if my civil rights have been suspended, they have
been fully restored.
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
petition and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.

Dated: ______________________ _____________________________________________
Signature of PETITIONER

Florida Supreme Court Approved Family Law Form 12.982(a), Petition for Change of Name (Adult) (03/15)
- 701 -
STATE OF FLORIDA
COUNTY OF ____________________

Sworn to or affirmed and signed before me on ____________ by _______________________________.

_____________________________________________
NOTARY PUBLIC or DEPUTY CLERK

_____________________________________________
[Print, type, or stamp commissioned name of notary or
deputy clerk.]
____ Personally known
____ Produced identification
____ Type of identification produced ________________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the Petitioner.
This form was completed with the assistance of:
{name of individual} ______________________________________________________________ ,
{name of business} _______________________________________________________________ ,
{address} _______________________________________________________________________ ,
{city} ______________, {state} ______,{ zip code}_______, {telephone number} _________________ .

Florida Supreme Court Approved Family Law Form 12.982(a), Petition for Change of Name (Adult) (03/15)
- 702 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
IN RE: THE NAME CHANGE OF

__ ,
Petitioner.

FINAL JUDGMENT OF CHANGE OF NAME (ADULT)
This cause came before the Court on {date} , for a hearing on Petition for Change of
Name (Adult) under section 68.07, Florida Statutes, and it appearing to the Court that:

1. Petitioner is a bona fide resident of County, Florida;

2. Petitioner’s request is not for any ulterior or illegal purpose; and

3. Granting this petition will not in any manner invade the property rights of others, whether
partnership, patent, good will, privacy, trademark, or otherwise; it is

ORDERED that Petitioner’s present name, ____________________________________________ ,
is changed to ___________________________________________________________________ ,
by which Petitioner shall hereafter be known.

DONE and ORDERED ON in ______________________________ , Florida.

CIRCUIT JUDGE

I certify that a copy of the {name of document(s)} ____________________________________________
was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the party(ies) listed below on
{date} __________________________________.

Petitioner

Florida Supreme Court Approved Family Law Form 12.982(b), Final Judgment of Change of Name (Adult) (03/15)
- 703 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY
LAW FORM 12.982(c)
PETITION FOR CHANGE OF NAME (MINOR CHILD(REN)) (03/15)

When should this form be used?

This form should be used when a parent or parents want the court to change the name of their
minor child(ren). For the purposes of this proceeding, a person under the age of 18 is a minor.
This form is not to be used in connection with an adoption, dissolution of marriage, or paternity
action. If you want a change of name for your child(ren) because of an adoption or paternity
action that is not yet final, the change of name should be requested as part of that case.

This form should be typed or printed in black ink and must be signed before a notary public or
deputy clerk. You should file the original with the clerk of the circuit court, in the county where
you live and keep a copy for your records. The Petition should only be completed by one
Petitioner for one child. If you wish to change the name of more than one child or if there is
more than one Petitioner, you should complete and file a Supplemental Form for Petition for
Change of Name (Minor Child) for each child and/or a Supplemental Form for Petition for
Change of Name. The supplemental form(s) is an attachment to the petition. Be sure that the
bottom of each page of each supplemental form is initialed by the petitioner(s).

IMPORTANT INFORMATION REGARDING E-FILING

The Florida Rules of Judicial Administration now require that all petitions, pleadings, and
documents be filed electronically except in certain circumstances. Self-represented litigants
may file petitions or other pleadings or documents electronically; however, they are not
required to do so. If you choose to file your pleadings or other documents electronically, you
must do so in accordance with Florida Rule of Judicial Administration 2.525, and you must follow
the procedures of the judicial circuit in which you file. The rules and procedures should be
carefully read and followed.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions for Florida Supreme Court Approved Family Law Form 12.982(c), Petition for Change of Name
(Minor Child(ren) (03/15)
- 704 -
SELF-REPRESENTED LITIGANTS MAY SERVE DOCUMENTS BY E-MAIL; HOWEVER, THEY ARE NOT
REQUIRED TO DO SO. If a self-represented litigant elects to serve and receive documents by e-
mail, the procedures must always be followed once the initial election is made.

To serve and receive documents by e-mail, you must designate your e-mail addresses by using
the Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family
Law Form 12.915, and you must provide your e-mail address on each form on which your
signature appears. Please CAREFULLY read the rules and instructions for: Certificate of Service
(General), Florida Supreme Court Approved Family Law Form 12.914; Designation of Current
Mailing and E-mail Address, Florida Supreme Court Approved Family Law Form 12.915; and
Florida Rule of Judicial Administration 2.516.

What should I do next?

Unless you are seeking to restore a former name, each adult petitioner(s)’s fingerprints must
be submitted for a state and national criminal history records check. The fingerprints must be
taken in a manner approved by the Department of Law Enforcement. The fingerprints must be
submitted to the Department of Law Enforcement for a state and national criminal history
records check. The Petitioner(s) may not request a hearing on the Petition until the copy of the
fingerprints are filed and the clerk of court has received the results of the criminal history
records check. The clerk of court can instruct you on the process for having the fingerprints
taken and submitted, including information on law enforcement agencies or service providers
authorized to submit fingerprints electronically to the Department of Law Enforcement. The
process may take several weeks and the parent or guardian of the minor must pay the cost of
processing the fingerprints and conducting the state and national history records check.

If both parents agree to the change of name and live in the county where the change of name is
sought, you may both file as petitioners. In this situation, service is not necessary, and you
need only to set a hearing. You should ask the clerk of court, family law intake staff, or judicial
assistant about the local procedure for setting a hearing.

If only one parent is a resident of the county where the change of name(s) is sought or only one
parent asks for the child(ren)’s name(s) to be changed, the other parent must be notified and his
or her consent obtained, if possible. If the other parent consents to the change of name, a
Consent for Change of Name (Minor Child(ren)), Florida Supreme Court Approved Family Law
Form 12.982(d), should be filed.

If the other parent does not consent to the change of name, you may still have a hearing on the
petition if you have properly notified the other parent about your petition and the hearing. If

Instructions for Florida Supreme Court Approved Family Law Form 12.982(c), Petition for Change of Name
(Minor Child(ren) (03/15)
- 705 -
you know where he or she lives, you must use personal service. If you absolutely do not know
where he or she lives, you may use constructive service. For more information about personal
and constructive service, you should refer [to] the “General Instructions for Self-Represented
Litigants” found at the beginning of these forms and the instructions to Florida Family Law Rules
of Procedure Forms 12.910(a) and 12.913(b) and Florida Supreme Court Approved Family Law
Form 12.913(a). However, the law regarding constructive service is very complex and you may
wish to consult an attorney regarding that issue.

Next, you must obtain a final hearing date for the court to consider your request. If you are
seeking to restore a former name, a hearing on the petition MAY be held immediately after the
petition is filed. The final hearing on any other petition for a name change may be held
immediately after the clerk of court receives the results of your criminal history records check.
You should ask the clerk of court, family law intake staff, or judicial assistant about the local
procedure for setting a hearing. You may be required to attend the hearing. Included in these
forms is a Final Judgment of Change of Name (Minor Child(ren)), Florida Supreme Court
Approved Family Law Form 12.982(e), which may be used when a judge grants a change of
name for a minor child(ren). If you attend the hearing, you should take the final judgment with
you. You should complete the top part of the form, including the circuit, county, case number,
division, and the name(s) of the petitioner(s) and leave the rest blank for the judge to complete.
It should be typed or printed in black ink.

If the judge grants your petition, he or she will sign this order. This officially changes your
child(ren)’s name(s). The clerk can provide you with certified copies of the signed order. There
will be charges for the certified copies, and the clerk can tell you the amount of the charges.

Where can I look for more information?

Before proceeding, you should read “General Information for Self-Represented Litigants”
found at the beginning of these forms. For further information, see section 68.07, Florida
Statutes.

Special notes...

The heading of the form calls for the name(s) of the petitioner(s). This means the parent(s) who
is (are) requesting the change of their child(ren)’s name(s). The judicial circuit, case number,
and division may be obtained from the clerk of court’s office when you file the petition.

Instructions for Florida Supreme Court Approved Family Law Form 12.982(c), Petition for Change of Name
(Minor Child(ren) (03/15)
- 706 -
etc. A list will help you know how many copies of your order you should get from the clerk of
court after your hearing.

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill
out these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida
Family Law Rules of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping
you fill out these forms also must put his or her name, address, and telephone number on the
bottom of the last page of every form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.982(c), Petition for Change of Name
(Minor Child(ren) (03/15)
- 707 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
IN RE: THE NAME CHANGE OF

,
Petitioner/Father,

,
Petitioner/Mother.

PETITION FOR CHANGE OF NAME (MINOR CHILD(REN))
I/We, {full legal name(s)} , being sworn, certify
that the following information is true:

I am/We are the birth or legal parent(s) or guardian of the minor child(ren) named in this petition.
{Choose only one}
a. _____ There is only one minor child named in this petition.
b. _____ There are {enter number of children} children named in this petition. The
information on the first child is entered below. I/We have attached the completed
supplemental forms for each other child.

The adult petitioner(s)’s fingerprints have been taken in a manner approved by the Department of Law
Enforcement and submitted for a state and national criminal history records check. I /We understand
that I/we cannot request a hearing on my/our Petition until the clerk of court receives the results of
the criminal history records check.

A. THE FOLLOWING INFORMATION IS TRUE ABOUT CHILD # 1 :

1. Minor child’s complete present name is:

I/We request that this minor child’s name be changed to:

2. The minor child lives in County, Florida, at {street address}

PETITIONER(S) MUST INITIAL HERE
Florida Supreme Court Approved Family Law Form 12.982(c), Petition for Change of Name (Minor Child(ren))
(03/15)
- 708 -
3. The minor child was born on {date} , in {city, county, state, country}

4. The minor child’s father’s full legal name: .
The minor child’s mother’s full legal name: .
The minor child’s mother’s maiden name: .

5. The minor child has lived in the following places since birth:
Dates (to/from) Address
_______/________ ______________________________________________________
_______/________ ______________________________________________________
_______/________ _______________________________________________________
_______/________ ______________________________________________________
_______/________ ______________________________________________________
(____ Please indicate here if you are continuing these facts on an attached page.)

6. {Choose one only}
____ The minor child is not married.
____ The minor child is married to: {full legal name} __________________________________.

7. {Choose one only}
____ The minor child has no children.
____ The minor child is the parent of the following child(ren): {enter full name(s) and date(s) of
birth} ___________________________________________________________________.

8. Former names.
{Indicate all that apply}
_____ The minor child’s name has never been changed by a court.
_____ The minor child’s name previously was changed by court order from _______________
to on {date} ,
by {court, city, and state} .
A copy of the court order is attached.

_____ The minor child’s name previously was changed by marriage from _________________
to on {date} ,
in {city, county, and state} .
A copy of the marriage certificate is attached.

_____ The minor child has never been known or called by any other name.
_____ The minor child has been known or called by the following other name(s): {list name(s)
and explain where child was known or called by such name(s)} ____________________
_____________________________________________________________________

PETITIONER(S) MUST INITIAL HERE
Florida Supreme Court Approved Family Law Form 12.982(c), Petition for Change of Name (Minor Child(ren))
(03/15)
- 709 -
_____________________________________________________________________

9. The minor child is not employed in an occupation or profession, does not own and operate a
business, and has received no educational degrees. If the minor child has a job, explain:

10. Criminal History.
{Choose one only}
_____ The minor child has never been arrested for or charged with, pled guilty or nolo
contendere to, or been found to have committed a criminal offense, regardless of
adjudication.
_____ The minor child has a criminal history. In the past, the minor child was arrested for or
charged with, pled guilty or nolo contendere to, or been found to have committed a
criminal offense, regardless of adjudication. The details of the criminal history are:

Date City/State Event (arrest, charge, plea, or adjudication)

(_____ Please indicate here if you are continuing these facts on an attached page.)

11. Money Judgments.
{Choose one only}
_____ The minor child has never been adjudicated bankrupt, and no money judgment has ever
been entered against him or her.
_____ The following money judgment(s) has been entered against him or her:
Date Amount Creditor Court entering judgment and case number {date) if Paid
________
________

B. THE FOLLOWING INFORMATION IS TRUE ABOUT PETITIONER(S):
_____ FATHER _____ MOTHER _____GUARDIAN
_____ A Supplemental Form has been attached for the other parent or petitioner.

1. My complete present name is: __________________________________________________
______________________________________________________________________________

2. I live in ________________ County, Florida, at {street address} ___________________________
______________________________________________________________________________ .

3. I have no ulterior or illegal purpose for filing this petition, and granting it will not in any manner
invade the property rights of others, whether partnership, patent, good will, privacy, trademark,
or otherwise.

PETITIONER(S) MUST INITIAL HERE
Florida Supreme Court Approved Family Law Form 12.982(c), Petition for Change of Name (Minor Child(ren))
(03/15)
- 710 -
4. My civil rights have never been suspended, or, if ever suspended, they have been fully restored.

PETITIONER(S) MUST INITIAL HERE
Florida Supreme Court Approved Family Law Form 12.982(c), Petition for Change of Name (Minor Child(ren))
(03/15)
- 711 -
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
petition and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.

Dated: ______
Signature of Petitioner
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es): __________________
____________________________________

STATE OF FLORIDA
COUNTY OF

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

____________________________________
{Print, type, or stamp commissioned name of notary or
clerk.}

__ Personally known
__ Produced identification
Type of identification produced

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the Petitioner(s).
This form was completed with the assistance of:
{name of individual} ___________________________________________________________ ,
{name of business} ______________________________________________________________ ,
{address}__________________________________________________________________________ ,
{city} ______,{state} __,{zip code}__________, {telephone number} .

PETITIONER(S) MUST INITIAL HERE
Florida Supreme Court Approved Family Law Form 12.982(c), Petition for Change of Name (Minor Child(ren))
(03/15)
- 712 -
ADULT SUPPLEMENTAL FORM FOR PETITION FOR CHANGE OF NAME (MINOR CHILDREN)

Case No.: ______________________________

THE FOLLOWING INFORMATION IS TRUE ABOUT PETITIONER(S):
( ) FATHER ( ) MOTHER ( ) GUARDIAN

1. My complete present name is: __________________________________________________
______________________________________________________________________________

2. I live in ________________ County, Florida, at {street address} ___________________________
______________________________________________________________________________.

4. My civil rights have never been suspended, or, if ever suspended, they have been fully restored.

Dated:
Signature of Petitioner
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es):____________________
STATE OF FLORIDA
COUNTY OF

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

[Print, type, or stamp commissioned name of notary or
clerk.]
__ Personally known
PETITIONER(S) MUST INITIAL HERE
Florida Supreme Court Approved Family Law Form 12.982(c), Petition for Change of Name (Minor Child(ren))
(03/15)
- 713 -
__ Produced identification
Type of identification produced
IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the Petitioner(s).
This form was completed with the assistance of:
{name of individual} ___________________________________________________________ ,
{name of business} ______________________________________________________________ ,
{address}__________________________________________________________________________ ,
{city} ______,{state} __,{zip code}__________, {telephone number} .

PETITIONER(S) MUST INITIAL HERE
Florida Supreme Court Approved Family Law Form 12.982(c), Petition for Change of Name (Minor Child(ren))
(03/15)
- 714 -
SUPPLEMENTAL FORM FOR PETITION FOR CHANGE OF NAME (MINOR CHILD(REN))

Case No.:

THE FOLLOWING INFORMATION IS TRUE ABOUT CHILD # :

1. Minor child’s complete present name is:
.
I/We request that minor child’s name be changed to:
.

2. The minor child lives in County, Florida, at {street address}
.

3. The minor child was born on {date} , in {city, county, state, country}
________________________________________________________________________ .

4. The minor child’s father’s full legal name: .
The minor child’s mother’s full legal name: .
The minor child’s mother’s maiden name: .

5. The minor child has lived in the following places since birth:
Dates (to/from) Address
/
/
/
/
/
/
(____ Please indicate here if you are continuing these facts on an attached page.)

6. [Choose one only]
The minor child is not married.
The minor child is married to: {full legal name} .

7. [Choose one only]
The minor child has no children.
The minor child is the parent of the following child(ren): {enter name(s) and date(s) of birth}
.

PETITIONER(S) MUST INITIAL HERE
Florida Supreme Court Approved Family Law Form 12.982(c), Petition for Change of Name (Minor Child(ren))
(03/15)
- 715 -
8. Former names
[Choose all that apply]
___ The minor child’s name has never been changed by a court.
___ The minor child’s name previously was changed by court order from
to on {date} ,
by {court, city, and state} .
A copy of the court order is attached.
___ The minor child’s name previously was changed by marriage from
to on {date} ,
in {city, county, and state} .
A copy of the marriage certificate is attached.
___ The minor child has never been known or called by any other name.
___ The minor child has been known or called by the following other name(s): {list name(s) and
explain where child was known or called by such name(s)}
___________________________________________________________________________
___________________________________________________________________________

9. The minor child is not employed in an occupation or profession, does not own and operate a
business, and has received no educational degrees. If the minor child has a job, explain:
________________________________________________________________________.

10. Criminal History
[Choose one only]
___ The minor child has never been arrested for or charged with, pled guilty or nolo contendere
to or been found to have committed a criminal offense, regardless of adjudication.
___ The minor child has a criminal history. In the past, the minor child was arrested for or
charged with, pled guilty or nolo contendere to, or been found to have committed a
criminal offense, regardless of adjudication. The details of the criminal history are:

Date City/State Event (arrest, charge, plea, or adjudication)

(____ Please indicate here if you are continuing these facts on an attached page.)

11. Money Judgments
[Choose one only]
_____ The minor child has never been adjudicated bankrupt, and no money judgment has ever
been entered against him or her.
_____ The following money judgment(s) has (have) been entered against him or her:
Date Amount Creditor Court entering judgment and case number {date} if Paid
_______

PETITIONER(S) MUST INITIAL HERE
Florida Supreme Court Approved Family Law Form 12.982(c), Petition for Change of Name (Minor Child(ren))
(03/15)
- 716 -
PETITIONER(S) MUST INITIAL HERE
Florida Supreme Court Approved Family Law Form 12.982(c), Petition for Change of Name (Minor Child(ren))
(03/15)
- 717 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.982(d),
CONSENT FOR CHANGE OF NAME (MINOR CHILD(REN))(03/15)

When should this form be used?

This form should be used when one parent consents to the other parent’s petition to change the name
of their minor child(ren). A parent who is not a petitioner in the case but is consenting to the change of
name should complete this form and sign it in front of a notary public or deputy clerk.

This form should be typed or printed in black ink. After this form is signed and notarized, you should file
it with the clerk of the circuit court in the county where the petition was filed and keep a copy for your
records. This form should be attached to the Petition for Change of Name (Minor Child(ren)), Florida
Supreme Court Approved Family Law Form 12.982(c), if obtained prior to the filing of the petition.
Otherwise, it may be filed separately after it has been completed.

IMPORTANT INFORMATION REGARDING E-FILING

Where can I look for more information?

Before proceeding, you should read General Information for Self-Represented Litigants found at the
beginning of these forms. For further information see section 68.07, Florida Statutes, and the
instructions for Petition for Change of Name (Minor Child(ren)), Florida Supreme Court Approved
Family Law Form 12.982(c), or Petition for Change of Name (Family), Florida Supreme Court Approved
Family Law Form 12.982(f).

Special notes...

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every

Instructions for Florida Supreme Court Approved Family Law Form 12.982(d), Consent for Change of Name (Minor
Child(ren)) (03/15)
- 718 -
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.982(d), Consent for Change of Name (Minor
Child(ren)) (03/15)
- 719 -
IN THE CIRCUIT COURT OF THE _ JUDICIAL CIRCUIT,
IN AND FOR _______________ COUNTY, FLORIDA

Case No.:
Division:
IN RE: THE NAME CHANGE OF

___________________,
Petitioner.

CONSENT FOR CHANGE OF NAME (MINOR CHILD(REN))

I, {full legal name} , being sworn, certify that the
following information is true:
I am the birth or legal _____ father _____ mother of the minor child(ren) named in this case, and I give
consent for the following name changes:

Minor child(ren)’s complete present name(s):
(1)
(2)
(3)
(4)
(5)
(6)

Dated: _____ ______________________________________________
Signature of Consenting Parent
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es): ____________________

Florida Supreme Court Approved Family Law Form 12.982(d), Consent for Change of Name (Minor Child(ren))
(03/15)
- 720 -
_____________________________________________

STATE OF FLORIDA
COUNTY OF

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

{Print, type, or stamp commissioned name of notary or
clerk.}
__Personally known
__Produced identification
Type of identification produced

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose one} ( ) petitioner ( ) consenting parent
This form was completed with the assistance of:
{name of individual} _________________________________________________________________ ,
{name of business} _____________________________________________________________________,
{address} ____________________________________________ ,
{city} ____________,{state} ___,{zip code}_____________, {telephone number} _______.

Florida Supreme Court Approved Family Law Form 12.982(d), Consent for Change of Name (Minor Child(ren))
(03/15)
- 721 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT
IN AND FOR _COUNTY, FLORIDA

Case No.:
Division:
IN RE: THE NAME CHANGE OF

,
Petitioner/Father,

_,
Petitioner/Mother.

FINAL JUDGMENT OF CHANGE OF NAME (MINOR CHILD(REN))

This cause came before the Court on {date} ______, for a hearing on Petition for
Change of Name under section 68.07, Florida Statutes, and it appearing to the Court that:

1. Petitioner(s) is (are) a bona fide resident(s) of County, Florida;

2. ___ Petitioners are the parents of the minor child(ren) named in the petition;

3. ___ Petitioner is the parent of the minor child(ren) named in the petition, and the other
parent has been properly notified and has either consented or failed to respond;
___ Other:

;

4. Petitioner’s request is not for any ulterior or illegal purpose; and

5. Granting this petition will not in any manner invade the property rights of others, whether
partnership, patent, good will, privacy, trademark, or otherwise; it is

ORDERED that the minor child(ren)’s
present name(s) ________________
(1) by which they shall hereafter be known.
(2) be changed to
(3) (1)
(4) (2)
(5) (3)
(6) (4)
______________________ (5)

Florida Supreme Court Approved Family Law Form 12.982(e), Final Judgment of Change of Name (Minor Child(ren))
(03/15)
- 722 -
(6)
DONE and ORDERED ON in _________________________, Florida.

CIRCUIT JUDGE

I certify that a copy of the {name of documents(s)} ___________________________________ was ( )
mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the parties and any other persons or
entities listed below on {date} _________________________.

________________________________________
Clerk of Court, Designee, or Judicial Assistant

Petitioner(s) (or his, her, or their attorney)
Other: _____________________________

Florida Supreme Court Approved Family Law Form 12.982(e), Final Judgment of Change of Name (Minor Child(ren))
(03/15)
- 723 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.982(f),
PETITION FOR CHANGE OF NAME (FAMILY) (03/15)
When should this form be used?

This form should be used when a family wants the court to change its name. This form is not to be used
in connection with a dissolution of marriage, paternity, or adoption action. If you want a change of
name because of a dissolution of marriage, paternity, or adoption action that is not yet final, the change
of name should be requested as part of that case.

This form should be typed or printed in black ink and must be signed before a notary public or deputy
clerk. You should file the original with the clerk of the circuit court in the county where you live and
keep a copy for your records. The petition should only be completed for one adult. If you wish to
change the name(s) of another adult and/or any child(ren), you should complete and file with the clerk
of court the attached Supplemental Form(s) for Petition for Change of Name (Family) for each additional
family member. Be sure that the bottom of each page of each supplemental form is initialed.

IMPORTANT INFORMATION REGARDING E-FILING

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

To serve and receive documents by e-mail, you must designate your e-mail addresses by using the

Instructions for Florida Supreme Court Approved Family Law Form 12.982(f), Petition for Change of Name (Family)
(03/15)
- 724 -
Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family Law Form
12.915, and you must provide your e-mail address on each form on which your signature appears.
Please CAREFULLY read the rules and instructions for: Certificate of Service (General), Florida Supreme
Court Approved Family Law Form 12.914; Designation of Current Mailing and E-mail Address, Florida
Supreme Court Approved Family Law Form 12.915; and Florida Rule of Judicial Administration 2.516.

What should I do next?

Unless you are seeking to restore a former name, each adult petitioner must have fingerprints
submitted for a state and national criminal history records check. The fingerprints must be taken in a
manner approved by the Department of Law Enforcement and must be submitted to the Department
for a state and national criminal history records check. You may not request a hearing on the petition
until the clerk of court has received the results of your criminal history records check. The clerk of
court can instruct you on the process for having the fingerprints taken and submitted, including
information on law enforcement agencies or service providers authorized to submit finger prints
electronically to the Department of Law Enforcement. The process may take several weeks and you will
have to pay for the cost of processing the fingerprints and conducting the state and national criminal
history records check.

If any of the children for whom you are requesting this change of name are not the legal children of both
adults filing this petition, you must obtain the consent of the legal parent(s). A parent not named as a
petitioner in this action may consent by submitting a Consent for Change of Name (Minor Child(ren)),
Florida Supreme Court Approved Family Law Form 12.982(d).

If the other parent does not consent to the change of name, you may still have a hearing on the petition
if you have properly notified the other parent about your petition and the hearing. If you know where
he or she lives, you must use personal service. If you absolutely do not know where he or she lives, you
may use constructive service. For more information about personal and constructive service, you should
refer to the General Instructions for Self-Represented Litigants found at the beginning of these forms
and the instructions to Florida Family Law Rules of Procedure Forms 12.910(a) and 12.913(b) and
Florida Supreme Court Approved Family Law Form 12.913(a). The law on constructive service is very
complex and you may wish to consult an attorney regarding constructive service.

Before a final hearing on your request may be held, you must obtain a date for the court to consider
your request. If you are seeking to restore a former name, the final hearing on the petition MAY be held
immediately after the petition is filed. The final hearing on any other petition for a name change may be
held immediately after the clerk of court receives the results of your criminal history records check. You
should ask the clerk of court, family law intake staff, or judicial assistant about the local procedure for
setting a hearing. You may be required to attend the hearing. Included in these forms is a Final
Judgment of Change of Name (Family), Florida Supreme Court Approved Family Law Form 12.982(g),
which may be used when a judge grants a change of name for a family. If you attend the hearing, you

Instructions for Florida Supreme Court Approved Family Law Form 12.982(f), Petition for Change of Name (Family)
(03/15)
- 725 -
should take the final judgment form with you. You should complete the top part of this form, including
the circuit, county, case number, division, the name(s) of the petitioner(s) and leave the rest blank for
the judge to complete. It should be typed or printed in black ink.

If the judge grants your petition, he or she will sign this order. This officially changes your family’s
name. The clerk can provide you with certified copies of the signed order. There will be charges for the
certified copies, and the clerk can tell you the amount of the charges.

Where can I look for more information?

Before proceeding, you should read “General Information for Self-Represented Litigants” found at the
beginning of these forms. For further information, see section 68.07, Florida Statutes.

Special notes...

The heading of the form calls for the name(s) of the petitioner(s). This is (are) the parent(s) who is/are
requesting the change of their family’s name(s). The judicial circuit, case number, and division may be
obtained from the clerk of court’s office when you file the petition.

It may be helpful to compile a list of all of the people and places that will need a copy of the final
judgment. This list may include the driver’s license office, social security office, banks, schools, etc. A list
will help you know how many copies of your order you should get from the clerk of court after your
hearing.

Instructions for Florida Supreme Court Approved Family Law Form 12.982(f), Petition for Change of Name (Family)
(03/15)
- 726 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
IN RE: THE NAME CHANGE OF

,
Petitioner/Father,

,
Petitioner/Mother.

PETITION FOR CHANGE OF NAME (FAMILY)
I/We, {full legal name(s)} , ____________________________________________________being sworn,
certify that the following information is true:
There are {enter number} _____ adults named in this petition. A supplemental form is attached for
each adult not set out below.
There are {enter number} _____ children named in this petition. I am/We are the birth or legal
parents or guardian of the minor child(ren) named in this petition. I/We have attached a completed
supplemental form for each minor child.
Unless I am seeking to restore a former name, a copy of the fingerprints of each adult person seeking a
name change in this petition has/have been taken in a manner approved by the Department of Law
Enforcement, and submitted for a state and national criminal history records check. I/We understand
that I/We cannot request a hearing on my/our Petition until the clerk of court receives the results of
the criminal history records check.

THE FOLLOWING INFORMATION IS TRUE ABOUT PETITIONER:
_____ HUSBAND _____ WIFE _____ GUARDIAN
_____ A Supplemental Form has been attached for the other parent or petitioner.

1. My complete present name is:
.
I request that my name be changed to:
.

2. I live in ___________ County, Florida, at {street address}
.

3. I was born on {date} ____________, in {city} ________________ ,
{county} ________________,{state} , {country} _______________ .

Florida Supreme Court Approved Family Law Form 12.982(f), Petition for Change of Name (Family) (03/15)
- 727 -
4. My father’s full legal name: .
My mother’s full legal name: .
My mother’s maiden name: .

5. I have lived in the following places since birth:
Dates (to/from) Address
/
/
/
/
/
/
/
/
(____ Please indicate here if you are continuing these facts on an attached page.)

6. Family
{Indicate all that apply}
a. ____ I am not married.
b. ____ I am married. My spouse’s full legal name is: .
c. ____ I do not have child(ren).
d. ____ The name(s), age(s), and address(es) of my child(ren) are as follows (all children,
including those over 18, must be listed):
Name {last, first, middle initial} Age Address, City, State

(____ Please indicate here if you are continuing these facts on an attached page.)
7. Former names
{Indicate all that apply}
_____ My name has never been changed by a court.

_____ My name previously was changed by court order from
to on {date} ,
by {court, city, and state} .
A copy of the court order is attached.

_____ My name previously was changed by marriage from
to on {date} ,
in {city, county, and state} .

Florida Supreme Court Approved Family Law Form 12.982(f), Petition for Change of Name (Family) (03/15)
- 728 -
A copy of the marriage certificate is attached.

_____ I have never been known or called by any other name.

_____ I have been known or called by the following other name(s): {list name(s) and explain
where you were known or called by such name(s)} _______________________________

8. Occupation
My occupation is: .
I am employed at: {company and address}
.
During the past 5 years, I have had the following jobs:

Dates (to/from) Employer and employer’s address
/
/
/
/
/
(____ Please indicate here if you are continuing these facts on an attached page.)

9. Business
{Choose one only}
_____I do not own and operate a business.

_____I own and operate a business. The name of the business is: .
The street address is: .
My position with the business is: .
I have been involved with the business since: {date} .

10. Profession
{Choose one only}
_____I am not in a profession.

_____I am in a profession. My profession is: .
I have practiced this profession:

Dates (to/from) Place and address
____/____ __________________________________________________________
____/ _ ______________________________________________________
____/ ______________________________________________________
____/ ______________________________________________________

Florida Supreme Court Approved Family Law Form 12.982(f), Petition for Change of Name (Family) (03/15)
- 729 -
(____ Please indicate here if you are continuing these facts on an attached page.)
11. Education
I have graduated from the following school(s):
Degree Date of
Received Graduation School

(____ Please indicate here if you are continuing these facts on an attached page.)

12. Criminal History
{Choose one only}
_____ I have never been arrested for or charged with, pled guilty or nolo contendere to, or
have been found to have committed a criminal offense, regardless of adjudication.

_____ I have a criminal history. In the past I have been arrested for or charged with, pled
guilty or nolo contendere to, or been found to have committed a criminal offense,
regardless of adjudication. The details of my criminal history are:

Date City/State Event (arrest, charge, plea, or adjudication)

(____ Please indicate here if you are continuing these facts on an attached page.)

13. Bankruptcy
{Choose one only}
_____I have never been adjudicated bankrupt.

_____I was adjudicated bankrupt on {date} , in {city} _____,
{county} , {state} .
(____ Please indicate here if you have had additional bankruptcies, and explain on an attached
page.)

14. Creditor(s)’ Judgments
{Choose one only}
_____I have never had a money judgment entered against me by a creditor.

_____ The following creditor(s)’ money judgment(s) have been entered against me:
Date Amount Creditor Court entering judgment and case number {date} if Paid

Florida Supreme Court Approved Family Law Form 12.982(f), Petition for Change of Name (Family) (03/15)
- 730 -
(____ Please indicate here if these facts are continued on an attached page.)

15. I have no ulterior or illegal purpose for filing this petition, and granting it will not in any manner
invade the property rights of others, whether partnership, patent, good will, privacy, trademark,
or otherwise.

16. My civil rights have never been suspended, or, if my civil rights have been suspended, they have
been fully restored.

Dated:
Signature of Petitioner
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es):__________________
________________________________

STATE OF FLORIDA
COUNTY OF
Sworn to or affirmed and signed before me on by _____________________.

NOTARY PUBLIC or DEPUTY CLERK

{Print, type, or stamp commissioned name of notary or
clerk.}
__ Personally known
__ Produced identification
Type of identification produced

Florida Supreme Court Approved Family Law Form 12.982(f), Petition for Change of Name (Family) (03/15)
- 731 -
IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the Petitioner.
This form was completed with the assistance of:
{name of individual} _________________________________________________________________ ,
{name of business} _____________________________________________________________________,
{address} ____________________________________________ ,
{city} ____________,{state} ___,{zip code}_____________, {telephone number} _______.

Florida Supreme Court Approved Family Law Form 12.982(f), Petition for Change of Name (Family) (03/15)
- 732 -
ADULT SUPPLEMENTAL FORM FOR PETITION FOR CHANGE OF NAME (FAMILY)

Case No.:

THE FOLLOWING INFORMATION IS TRUE ABOUT PETITIONER:
( ) HUSBAND ( ) WIFE ( ) GUARDIAN

1. My complete present name is:
.
I request that my name be changed to:
.

2. I live in ___________ County, Florida, at {street address}
.

3. I was born on {date} _______, in {city} ___________________,
{county} ________________,{state} , {country} ______________________ .

4. My father’s full legal name: .
My mother’s full legal name: .
My mother’s maiden name: .

5. I have lived in the following places since birth:
Dates (to/from) Address
/
/
/
/
/
/
/
/
/
(____ Please indicate here if you are continuing these facts on an attached page.)

6. Family{[Indicate all that apply}
a. ___ _ I am not married.

b. ____ I am married. My spouse’s full legal name is: .

c. ___ _ I do not have child(ren).

d. ___ _ The name(s), age(s), and address(es) of my child(ren) are as follows (all children,
including those over 18, must be listed):
PETITIONER(S) MUST INITIAL HERE
Florida Supreme Court Approved Family Law Form 12.982(f), Supplemental Form for Petition for Change of Name
(Family) (03/15)
- 733 -
Name {last, first, middle initial} Age Address, City, State

(____ Please indicate here if you are continuing these facts on an attached page.)

7. Former names
{Indicate all that apply}
____My name has never been changed by a court.

____My name previously was changed by court order from____________________________
to on {date}
by {court, city, and state} .
A copy of the court order is attached.

____My name previously was changed by marriage from ____________________________
to on {date}
in {city, county, and state} .
A copy of the marriage certificate is attached.

____I have never been known or called by any other name.

____I have been known or called by the following other name(s): {list name(s) and explain
where you were known or called by such name(s)} _______________________________

8. Occupation
My occupation is: .
I am employed at: {company and address}
.
During the past 5 years, I have had the following jobs:
Dates (to/from) Employer and employer’s address
/
/
/
/
/
/
/
(____ Please indicate here if you are continuing these facts on an attached page.)

9. Business
{indicate all that apply}
____ I do not own and operate a business.

PETITIONER(S) MUST INITIAL HERE
Florida Supreme Court Approved Family Law Form 12.982(f), Supplemental Form for Petition for Change of Name
(Family) (03/15)
- 734 -
PETITIONER # , continued

____ I own and operate a business. The name of the business is: .
The street address is: ___.
My position with the business is: .
I have been involved with the business since: {date} .

10. Profession
{Indicate all that apply}
____I am not in a profession.

____I am in a profession. My profession is: .
I have practiced this profession:
Dates (to/from) Place and address
/
/
/
/
(___ Please indicate here if you are continuing these facts on an attached page.)

11. Education
I have graduated from the following school(s):
Degree Date of
Received Graduation School

(___ Please indicate here if you are continuing these facts on an attached page.)

12. Criminal History
{Choose one only}
____I have never been arrested for or charged with, pled guilty or nolo contendere to, or been
found to have committed a criminal offense, regardless of adjudication.

____I have a criminal history. In the past I have been arrested for or charged with, pled guilty or
nolo contendere to, or been found to have committed a criminal offense, regardless of
adjudication. The details of my criminal history are:

Date City/State Event (arrest, charge, plea, or adjudication)

(___ Please indicate here if you are continuing these facts on an attached page.)

13. Bankruptcy
{Choose one only}

PETITIONER(S) MUST INITIAL HERE
Florida Supreme Court Approved Family Law Form 12.982(f), Supplemental Form for Petition for Change of Name
(Family) (03/15)
- 735 -
PETITIONER # , continued
____I have never been adjudicated bankrupt.

____I was adjudicated bankrupt on {date} , in {city} ,
{county} , {state} .
(___ Please indicate here if you have had additional bankruptcies, and explain on an attached
page.)

14. Creditors’ Judgments
{Choose one only}
____ I have never had a money judgment entered against me by a creditor.

____ The following creditor(s)’ money judgment(s) have been entered against me:
Date Amount Creditor Court entering judgment and case number {date} if Paid

(____ Please indicate here if these facts are continued on an attached page.)

16. My civil rights have never been suspended, or, if my civil rights have been suspended, they have
been fully restored.

Dated: ________________________ _____________________________________________
Signature of Petitioner
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es):___________________
STATE OF FLORIDA
COUNTY OF
Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

PETITIONER(S) MUST INITIAL HERE
Florida Supreme Court Approved Family Law Form 12.982(f), Supplemental Form for Petition for Change of Name
(Family) (03/15)
- 736 -
PETITIONER # , continued

[Print, type, or stamp commissioned name of notary or
clerk.]
__ Personally known
__ Produced identification
Type of identification produced

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the Petitioner.
This form was completed with the assistance of:
{name of individual} _________________________________________________________________ ,
{name of business} _____________________________________________________________________,
{address} ____________________________________________ ,
{city} ____________,{state} ___,{zip code}_____________, {telephone number} _______.

PETITIONER(S) MUST INITIAL HERE
Florida Supreme Court Approved Family Law Form 12.982(f), Supplemental Form for Petition for Change of Name
(Family) (03/15)
- 737 -
CHILD SUPPLEMENTAL FORM FOR PETITION FOR CHANGE OF NAME (FAMILY)

Case No.:

THE FOLLOWING INFORMATION IS TRUE ABOUT MINOR CHILD # :

1. Minor child’s complete present name is:

I/We request that minor child’s name be changed to:

2. The minor child lives in County, Florida, at {street address}
.

3. The minor child was born on , in {city, county, state, country}
.

4. The minor child’s father’s full legal name: .
The minor child’s mother’s full legal name: .
The minor child’s mother’s maiden name: .

5. The minor child has lived in the following places since birth:
Dates (to/from) Address
/
/
/
/
/
/
/
(____ Please indicate here if continuing these facts on an attached page.)

6. [Choose one only]
____The minor child is not married

____The minor child is married to: {full legal name} .

[Choose one only}
____ The minor child has no children.

____ The minor child is the parent of the following child(ren): {enter name(s) and date(s) of
birth} .

7. Former names
{Indicate all that apply}
____The minor child’s name has never been changed by court order.

____The minor child’s name previously was changed by court order from:
PETITIONER(S) MUST INITIAL HERE
Florida Supreme Court Approved Family Law Form 12.982(f), Supplemental Form for Petition for Change of Name
(Family) (03/15)
- 738 -
_______________________________to___________________________________
on {date}__________________ {court, city, and state} _______________________
____________________________________________________________________ .
A copy of the court order is attached.

____ The minor child’s name previously was changed by marriage from ______________
to on {date} __________, in {city,
county, and state} .
____The minor child has never been known or called by any other name.

____ The minor child has been known or called by the following other name(s): {list name(s)
and explain where child was known or called by such name(s)} _________
____________________________________________________________________
____________________________________________________________________ .

8. The minor child is not employed in an occupation or profession, does not own and operate a
business, and has received no educational degrees. If the minor child has a job, explain:
_____________________________________________________________
________________________________________________________________________
________________________________________________________________________

9. Criminal History
{Choose one only}
____ The minor child has never been arrested for or charged with, pled guilty or nolo
contendere to, or been found to have committed a criminal offense, regardless of
adjudication.

____ The minor child has a criminal history. In the past, the minor child was arrested for or
charged with, pled guilty or nolo contendere to, or been found to have committed a criminal
offense, regardless of adjudication. The details of the criminal history are:

Date City/State Event (arrest, charge, plea, or adjudication)

(____ Please indicate here if you are continuing these facts on an attached page.)

10. Money Judgments
{Choose one only}
____ The minor child has never been adjudicated bankrupt, and no money judgment has ever
been entered against him or her.

____ The following money judgment(s) has been entered against him or her:
Date Amount Creditor Court entering judgment and case number {date} if Paid

PETITIONER(S) MUST INITIAL HERE
Florida Supreme Court Approved Family Law Form 12.982(f), Supplemental Form for Petition for Change of Name
(Family) (03/15)
- 739 -
PETITIONER(S) MUST INITIAL HERE
Florida Supreme Court Approved Family Law Form 12.982(f), Supplemental Form for Petition for Change of Name
(Family) (03/15)
- 740 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
IN RE: THE NAME CHANGE OF

_,
Petitioner/Father,

,
Petitioner/Mother.

FINAL JUDGMENT OF CHANGE OF NAME (FAMILY)

This cause came before the Court on {date} , for a hearing on Petition for Change of
Name under section 68.07, Florida Statutes, and it appearing to the Court that:

1. Petitioners are bona fide residents of County, Florida;

2. a. _Petitioners are the parents of the minor child(ren) named in the petition;
b. _Petitioner is the parent of the minor child(ren) named in the petition, and the other parent
has been properly notified and has either consented or failed to respond;
c. _Other:
;

3. Petitioner’s request is not for any ulterior or illegal purpose; and

4. Granting this petition will not in any manner invade the property rights of others, whether
partnership, patent, good will, privacy, trademark, or otherwise; it is

ORDERED that the:
present be changed to
name(s) (1)
(1) (2)
(2) (3)
(3) (4)
(4) (5)
(5) (6)
(6)

Florida Supreme Court Approved Family Law Form 12.982(g), Final Judgment of Change of Name (Family) (03/15)
- 741 -
by which they shall hereafter be known.

DONE AND ORDERED on in _______________________________, Florida.

CIRCUIT JUDGE

I certify that a copy of the {name of document(s)} __________________________________
was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the parties and any
other persons or entities listed below on {date} ________________________.

_______________________________________
By: Clerk of Court, Designee, or Judicial Assistant

Petitioner(s) (or his/her/their attorney)
Other:__________________________

Florida Supreme Court Approved Family Law Form 12.982(g), Final Judgment of Change of Name (Family) (03/15)
- 742 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.983(a),
PETITION TO DETERMINE PATERNITY AND FOR RELATED RELIEF
(03/15)

When should this form be used?

This form should be used by a birth mother or father to ask the court to establish paternity, a time-
sharing schedule, and/or child support of a minor child or children. This means that you are trying to
legally establish who is the father of the child(ren).

IMPORTANT INFORMATION REGARDING E-FILING

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions for Florida Supreme Court Approved Family Law Form 12.983(a), Petition to Determine Paternity and
for Related Relief (03/15)
- 743 -
What should I do next?

For your case to proceed, you must properly notify the respondent of the petition. If you know where
he or she lives, you should use personal service. If you absolutely do not know where he or she lives,
you may use constructive service. However, if constructive service is used, the court may only grant
limited relief. You should seek legal advice on constructive service in a paternity case. For more
information see chapter 49, Florida Statutes, or you may contact Child Support Enforcement at the
Florida Department of Revenue if you need assistance with your case.

If personal service is used, the respondent has 20 days to answer after being served with your petition.
Your case will then generally proceed in one of the following three ways:

DEFAULT... If after 20 days, no answer has been filed, you may file a Motion for Default, Florida
Supreme Court Approved Family Law Form 12.922(a), with the clerk of court. Then, if you have filed all
of the required papers, you may call the clerk, family law intake staff, or judicial assistant to set a final
hearing. You must notify the other party of the hearing by using a Notice of Hearing (General), Florida
Supreme Court Approved Family Law Form 12.923, or other appropriate notice of hearing form.

UNCONTESTED... If the respondent files an answer that agrees with everything in your petition or an
answer and waiver, and you have complied with mandatory disclosure and filed all of the required
papers, you may call the clerk, family law intake staff, or judicial assistant to set a final hearing. You
must notify the other party of the hearing by using a Notice of Hearing (General), Florida Supreme Court
Approved Family Law Form 12.923, or other appropriate notice of hearing form.

CONTESTED... If the respondent files an answer or an answer and counterpetition, which disagrees
with or denies anything in your petition, and you are unable to settle the disputed issues, you should file
a Notice for Trial, Florida Supreme Court Approved Family Law Form 12.924, after you have complied
with mandatory disclosure, completed the scientific paternity testing, if necessary, and filed all of the
required papers. Then you should contact the clerk, family law intake staff, or judicial assistant for
instructions on how to set your case for trial (final hearing). If the respondent files an answer and
counterpetition, you should answer the counterpetition within 20 days using an Answer to
Counterpetition, Florida Supreme Court Approved Family Law Form 12.983(d).

Where can I look for more information?

Instructions for Florida Supreme Court Approved Family Law Form 12.983(a), Petition to Determine Paternity and
for Related Relief (03/15)
- 744 -
Special notes...

If you do not have the money to pay the filing fee, you may obtain an Application for Determination of
Civil Indigent Status, fill it out, and the clerk will determine whether you are eligible to have filing fees
deferred.

More than one child of the same alleged father may be listed on a single petition. However, if you are
filing a paternity action involving more than one possible father, a separate petition must be filed for
each alleged father.
If the respondent files an answer denying that the person named in the petition is the child(ren)’s
father, one of you should file a Motion for Scientific Paternity Testing, Florida Supreme Court Approved
Family Law Form 12.983(e). This is used to ask the court to order a scientific test to determine who is
the child(ren)’s father.

If the father signed papers at the hospital acknowledging that he was the father, paternity was
established as a matter of law. This should be indicated on page 2, section 9a on this form.

If the paternity of a child who was conceived or born during a marriage is at issue, the court may appoint
a guardian ad litem to assist the court in this matter and to protect the rights of child.

With this petition, you must file the following and provide a copy to the other party:
 Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida Supreme
Court Approved Family Law Form 12.902(d).
 Notice of Social Security Number, Florida Supreme Court Approved Family Law Form 12.902(j).
 Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or (c).
 Certificate of Compliance with Mandatory Disclosure, Florida Family Law Rules of Procedure
Form 12.932. (This must be filed within 45 days, if not filed with the petition, unless you and the
other party have agreed not to exchange these documents.)
 Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e). (If
you do not know the other party’s income, you may file this worksheet after his or her financial
affidavit has been filed.)
 Parenting Plan, Florida Supreme Court Approved Family Law Form, 12.995(a), 12.995(b), or
12.995(c). If the parents have reached an agreement, a signed and notarized Parenting Plan
should be attached. If the parents have not reached an agreement, a proposed Parenting Plan
may be filed.

Parenting Plan and Time-Sharing. If the parties are unable to agree on parenting arrangements and a
time-sharing schedule, a judge will decide as part of establishing a Parenting Plan. The judge will decide
the parenting arrangements and time-sharing based on the child(ren)’s best interests. Regardless of
whether there is an agreement between the parties, the court reserves jurisdiction to modify issues
relating to minor or dependent child(ren).

Instructions for Florida Supreme Court Approved Family Law Form 12.983(a), Petition to Determine Paternity and
for Related Relief (03/15)
- 745 -
issues. The purpose of such intervention is to be sure that the best interests of the child(ren) are being
served. For more information, you may consult sections 61.401–61.405, Florida Statutes.

 Shared Parental Responsibility
 Sole Parental Responsibility
 Supervised Time-Sharing
 No contact
• Parenting Plan
• Parenting Plan Recommendation
• Time-Sharing Schedule

Many circuits require that parents of a minor or dependent child(ren) who are involved in dissolution or
paternity actions attend mediation before being allowed to schedule a final hearing. A parenting
course must be completed prior to entry of the final judgment. You should check with your local clerk of
court’s office, family law intake staff, or judicial assistant for more information on the parenting course
and mediation requirements in your area.

Florida has adopted guidelines for determining the amount of child support to be paid. These guidelines
are based on the combined income of both parents and take into account the financial contributions of
both parents. You should file a financial affidavit, and the other parent will be required to do the same.
From your financial affidavits, you should be able to calculate the amount of child support that should
be paid. Because the child support guidelines take several factors into consideration, change over time,
and vary from state to state, your child support obligation may be more or less than that of other people
in seemingly similar situations.

Final Judgments. These family law forms contain a Final Judgment of Paternity, Florida Supreme Court
Approved Family Law Form 12.983(g), which the judge may use. You should check with the clerk, family
law intake staff, or judicial assistant to see if you need to bring it with you to the hearing. If so, you
should type or print the heading, including the circuit, county, case number, division, and the parties’
names, and leave the rest blank for the judge to complete at your hearing or trial.

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.983(a), Petition to Determine Paternity and
for Related Relief (03/15)
- 746 -
IN THE CIRCUIT COURT OF THE ________________ JUDICIAL CIRCUIT,
IN AND FOR ______________________________ COUNTY, FLORIDA

Case No: ________________________
Division: ________________________

_________________________________,
Petitioner,
And

_________________________________,
Respondent.

PETITION TO DETERMINE PATERNITY AND FOR RELATED RELIEF

Petitioner, {full legal name}____________________________, being sworn, certifies that the following
information is true:

This is an action for paternity and to determine parental responsibility, time-sharing, and child support
under chapter 742, Florida Statutes.

SECTION I.
1. Petitioner is the _____ Mother _____ Father of the following minor child(ren):
Name Birth Date
1.________________________________________________________________________

2. ________________________________________________________________________

3. ________________________________________________________________________

4. ________________________________________________________________________

5. ________________________________________________________________________

6. ________________________________________________________________________

2. Petitioner’ s current address is: {street address, city, state} __________________________________
_________________________________________________________________________________ .

3. Respondent’s current address is: {street address, city, state} ______________________________
________________________________________________________________________________
4. Both parties are over the age of 18.

Florida Supreme Court Approved Family Law Form 12.983(a), Petition to Determine Paternity and for Related
Relief (03/15)
- 747 -
5. Petitioner {Choose only one} _____ is _____ is not a member of the military service.
Respondent {Choose only one} _____ is _____ is not a member of the military service.

6. Neither Petitioner nor Respondent is mentally incapacitated.

7. A completed Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida
Supreme Court Approved Family Law Form 12.902(d), is filed with this petition.

8. A completed Notice of Social Security Number, Florida Supreme Court Approved Family Law Form
12.902(j), is filed with this petition.

9. A completed Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or
(c), is, or will be, filed.

10. Paternity Facts.
{Choose only one}
a. _____Paternity has previously been established as a matter of law.

b. _____The parties engaged in sexual intercourse with each other in the month(s) of {list month(s)
and year(s)} ____________________in {city and state} ________________________________
As a result of the sexual intercourse, _____ Petitioner _____ Respondent conceived and gave
birth to the minor child(ren) named in paragraph 1. _____ Petitioner _____Respondent is the
natural father of the minor child(ren). The mother _____ was _____ was not married at the
time of the conception and/or birth of the minor child(ren) named in paragraph 1. If the mother
was married, the name and address of her husband at the time of conception and/or birth is:
______________________________________________________________________________
___________________________________________________________________________

SECTION II. PARENTING PLAN ESTABLISHING PARENTAL RESPONSIBILITY AND TIME-SHARING

1. The minor child(ren) currently reside(s) with _____ Mother _____ Father _____ other: {explain}
_________________________________________________________________________________
_________________________________________________________________________________.

2. Parental Responsibility. It is in the child(ren)’s best interests that parental responsibility be:
{Choose only one}
a. _____ shared by both Father and Mother.

b. ____awarded solely to _____ Father _____ Mother. Shared parental responsibility would be
detrimental to the child(ren) because: ____________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.

3. Parenting Plan and Time-Sharing. It is in the best interests of the child(ren) that the family be
ordered to comply with a Parenting Plan that _____ includes _____does not include parental time-
Florida Supreme Court Approved Family Law Form 12.983(a), Petition to Determine Paternity and for Related
Relief (03/15)
- 748 -
sharing with the child(ren). The Petitioner states that it is in the best interests of the child(ren) that:
{Choose only one}
a. _____The attached proposed Parenting Plan should be adopted by the court.
The parties _____ have _____ have not agreed to the Parenting Plan.

b. _____ The court should establish a Parenting Plan with the following provisions:
1.____ No time-sharing for the _____ Father _____ Mother
2.____ Limited time-sharing with the _____ Father _____ Mother
3.____ Supervised time-sharing for the _____ Father _____ Mother.
4.____ Supervised or third-party exchange of the child(ren).
5.____ Time-sharing schedule as follows:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Explain why this schedule is in the best interests of the child(ren): _______________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

4. The minor child(ren) should
{Choose only one}
a. _____retain his/her (their) present name(s).

b. _____receive a change of name as follows:
present name(s) be changed to
(1). ____________________________________ (1). ___________________________________
(2). ____________________________________ (2). ___________________________________
(3). ____________________________________ (3). ___________________________________
(4). ____________________________________ (4). ___________________________________
(5). ____________________________________ (5). ___________________________________
(6). ____________________________________ (6). ___________________________________

c. The name change would be in the best interest of the child(ren) because:_________________
__________________________________________________________________________

SECTION III. CHILD SUPPORT
{Indicate all that apply}
1. _____Petitioner requests that the Court award child support as determined by Florida’s child
support guidelines, section 61.30, Florida Statutes. A completed Child Support Guidelines
Worksheet, Florida Family Law Rules of Procedure Form 12.902(e), is, or will be, filed. Such support
should be ordered retroactive to:
{Choose only one}
a. _____the date when the parents did not reside together in the same household with the child,
not to exceed a period of 24 months before the date of filing of this petition.

b. _____the date of the filing of this petition.

Florida Supreme Court Approved Family Law Form 12.983(a), Petition to Determine Paternity and for Related
Relief (03/15)
- 749 -
c. _____other: {date}________________ {Explain} ________________________________
______________________________________________________________________________

2. _____Petitioner requests that the Court award a child support amount that is more than or less than
Florida’s child support guidelines. Petitioner understands that a Motion to Deviate from Child
Support Guidelines, Florida Supreme Court Approved Family Law Form 12.943, must be completed
before the Court will consider this request.

3. _____Petitioner requests that medical/dental insurance for the minor child(ren) be provided by:
{Choose only one}
a. _____Father.

b. _____Mother.

4. _____Petitioner requests that uninsured medical/dental expenses for the child(ren) be paid by:
{Choose only one}
a. _____Father.
b. _____Mother.
c. _____Father and Mother each pay one-half.
d. _____Father and Mother each pay according to the percentages in the Child Support Guidelines
Worksheet, Florida Family Law Rules of Procedure Form 12.902(e).
e. _____Other {explain}: ___________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

5. _____Petitioner requests that life insurance to secure child support be provided by:
[Choose only one]
a. _____Father.
b. _____Mother.
c. _____Both

6. _____ Petitioner _____ Respondent _____ Both has (have) incurred medical expenses in the amount
of $__________ on behalf of the minor child(ren), including hospital and other expenses incidental
to the birth of the minor child(ren). There should be an appropriate allocation or apportionment of
these expenses.

7. _____ Petitioner _____ Respondent _____ Both has (have) received past public assistance for this
(these) minor child(ren).

PETITIONER’S REQUEST
1. Petitioner requests a hearing on this petition and understands that he or she must attend the
hearing.

2. Petitioner requests that the Court enter an order that:
[Indicate all that apply]
a. ____establishes paternity of the minor child(ren), ordering proper scientific testing, if
necessary;
Florida Supreme Court Approved Family Law Form 12.983(a), Petition to Determine Paternity and for Related
Relief (03/15)
- 750 -
b. _____adopts or establishes a Parenting Plan containing provisions for parental responsibility
and time-sharing for the minor or dependent child(ren);
c. _____awards child support, including medical/dental insurance coverage for the minor
child(ren);
d. _____determines the appropriate allocation or apportionment of all expenses incidental to
the birth of the child(ren), including hospital and medical expenses;
e. _____determines the appropriate allocation or apportionment of all other past, present,
and future medical and dental expenses incurred or to be incurred on behalf of the
minor child(ren);
f. _____changes the child(ren)’s name(s);
g. _____other relief as follows: ______________________________________________________
______________________________________________________________________________
______________________________________________________________________________
___________________________________________________________________________ and
grants such other relief as may be appropriate and in the best interests of the minor child(ren).

Dated: ______________________ _____________________________________________
Signature of PETITIONER
Printed Name: _________________________________
Address: _____________________________________
City, State, Zip: ________________________________
Telephone Number: _____________________________
Fax Number: __________________________________
Designated E-mail Address(es):____________________
_________________________________________
STATE OF FLORIDA
COUNTY OF ____________________

Sworn to or affirmed and signed before me on ____________ by _______________________________.

_____________________________________________
NOTARY PUBLIC or DEPUTY CLERK

_____________________________________________
{Print, type, or stamp commissioned name of notary or
deputy clerk.}
_____ Personally known
_____ Produced identification
_____ Type of identification produced ________________________________

Florida Supreme Court Approved Family Law Form 12.983(a), Petition to Determine Paternity and for Related
Relief (03/15)
- 751 -
IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the Petitioner.
This form was completed with the assistance of:
{name of individual} _______________________________________________________________ ,
{name of business}_________________________________________________________________ ,
{address} _________________________________________________________________________ ,
{city} _______________,{state} _______,{zip code}_________, {telephone number} ______________.

Florida Supreme Court Approved Family Law Form 12.983(a), Petition to Determine Paternity and for Related
Relief (03/15)
- 752 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.983(b)
ANSWER TO PETITION TO DETERMINE PATERNITY AND FOR RELATED
RELIEF (03/15)

When should this form be used?

This form should be used when you are responding to a petition to determine paternity. You may use
this form to admit or deny the allegations contained in the petition. However, if you wish to ask the
court for things not included in the petition, such as, parental responsibility and time-sharing or child
support, you should file an Answer to Petition and Counterpetition to Determine Paternity and for
Related Relief, Florida Supreme Court Approved Family Law Form 12.983(c).

This form should be typed or printed in black ink. After completing this form, you should sign this form
before a notary public or deputy clerk. You should then file the original with the clerk of the circuit
court in the county where the petition was filed and keep a copy for your records.

IMPORTANT INFORMATION REGARDING E-FILING

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

To serve and receive documents by e-mail, you must designate your e-mail addresses by using the

Instructions for Florida Supreme Court Approved Family Law Form 12.983(b), Answer to Petition to Determine
Paternity and for Related Relief (03/15)
- 753 -
Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family Law Form
12.915, and you must provide your e-mail address on each form on which your signature appears.
Please CAREFULLY read the rules and instructions for: Certificate of Service (General), Florida Supreme
Court Approved Family Law Form 12.914; Designation of Current Mailing and E-mail Address, Florida
Supreme Court Approved Family Law Form 12.915; and Florida Rule of Judicial Administration 2.516.

What should I do next?

If you deny that the person named in the petition is the child(ren)’s father, a Motion for Scientific
Paternity Testing, Florida Supreme Court Approved Family Law Form 12.983(e), should be filed. This is
used to ask the court to order a scientific test to determine who is the child(ren)’s father.

You have 20 days to file an answer to the other party’s petition. A copy of this form, along with all of
the other forms required with this answer, must be mailed, e-mailed, or hand delivered to the other
party in your case. After you file your answer, the case will generally proceed in one of the following two
ways:

UNCONTESTED… This case is uncontested if you and the petitioner agree on all issues raised in the
petition. If this is the case, and you and the other party have complied with mandatory disclosure and
filed all of the required papers, either party may call the clerk, family law intake staff, or judicial
assistant to set a final hearing. If you request the hearing, you must notify the other party of the
hearing by using a Notice of Hearing (General), Florida Supreme Court Approved Family Law Form
12.923, or other appropriate notice of hearing form.

CONTESTED… This case is contested if you and the other party disagree on any issues raised in the
petition. If you are unable to settle the disputed issues, either party may file a Notice for Trial Florida
Supreme Court Approved Family Law Form 12.924, after you have complied with mandatory disclosure
and filed all of the required papers. Some circuits may require the completion of mediation before a
final hearing may be set. You should contact the clerk, family law intake staff, or judicial assistant for
instructions on how to set your case for trial (final hearing).

Where can I look for more information?

Instructions for Florida Supreme Court Approved Family Law Form 12.983(b), Answer to Petition to Determine
Paternity and for Related Relief (03/15)
- 754 -
Special notes...

With this answer, you must file the following and provide a copy to the other party:

 Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida Supreme
Court Approved Family Law Form 12.902(d).
 Notice of Social Security Number, Florida Supreme Court Approved Family Law Form 12.902(j).
 Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902 (b)
or (c). (This must be filed within 45 days of the service of the petition on you, if not filed
at the time you file this answer.)
 Certificate of Compliance with Mandatory Disclosure, Florida Family Law Rules of
Procedure Form 12.932. (This must be filed within 45 days of the service of the petition
on you, if not filed at the time you file this answer, unless you and the other party have
agreed not to exchange these documents.)
 Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form
12.902(e). (If you do not know the other party’s income, you may file this form after the
other party files his or her financial affidavit.)

Many circuits require completion of mediation before being allowed to schedule a final hearing. A
parenting course must be completed prior to entry of the final judgment. You should check with your
local clerk, family law intake staff, or judicial assistant for more information on the parenting course and
mediation requirements in your area.

Parenting Plan and Time-Sharing. If the parents are unable to agree on parenting arrangements and a
time-sharing schedule, a judge will decide these issues as part of establishing a Parenting Plan. The judge
will decide the parenting arrangements and time-sharing schedule based on the child(ren)’s best
interests. Regardless of whether there is an agreement between the parties, the court reserves
jurisdiction to modify issues relating to minor child(ren).

Listed below are some terms with which you should become familiar before completing your answer. If
you do not fully understand any of the terms below or their implications, you should speak with an
attorney before going any further.

 Shared Parental Responsibility
 Sole Parental Responsibility
 Supervised Time-Sharing
 No contact

Instructions for Florida Supreme Court Approved Family Law Form 12.983(b), Answer to Petition to Determine
Paternity and for Related Relief (03/15)
- 755 -
 Parenting Plan
 Parenting Plan Recommendation
 Time-Sharing Schedule

Child Support… The court may order one parent to pay child support to assist the other parent in
meeting the child(ren)’s material needs. Both parents are required to provide financial support, but
one parent may be ordered to pay a portion of his or her support for the child(ren) to the other parent.
Florida has adopted guidelines for determining the amount of child support to be paid. These guidelines
are based on the combined income of both parents and take into account the financial contributions of
both parents. You should file a financial affidavit, and the other parent will be required to do the same.
From your financial affidavits, you should be able to calculate the amount of child support that should
be paid. Because the child support guidelines take several factors into consideration, change over time,
and vary from state to state, your child support obligation may be more or less than that of other people
in seemingly similar situations.

Final Judgments… These family law forms contain a Final Judgment of Paternity, Florida Supreme
Court Approved Family Law Form 12.983(g), which the judge may use. You should check with the clerk,
family law intake staff, or judicial assistant to see if you need to bring it with you to the hearing. If so,
you should type or print the heading, including the circuit, county, case number, division, and the
parties’ names, and leave the rest blank for the judge to complete at your hearing or trial.

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of a Disclosure from a Nonlawyer, Florida Family Law
Rules of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these
forms also must put his or her name, address, and telephone number on the bottom of the last page of
every form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.983(b), Answer to Petition to Determine
Paternity and for Related Relief (03/15)
- 756 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
,
Petitioner,

and

,
Respondent.

ANSWER TO PETITION TO DETERMINE PATERNITY
AND FOR RELATED RELIEF

I, {full legal name} , Respondent, being
sworn, certify that the following information is true:

1. I agree with Petitioner as to the allegations raised in the following numbered paragraphs in the
Petition and, therefore, admit those allegations: {indicate section and paragraph number}
.

2. I disagree with Petitioner as to the allegations raised in the following numbered paragraphs in
the Petition and, therefore, deny those issues: {indicate section and paragraph number}
.

3. I currently am unable to admit or deny the following paragraphs due to lack of information:
{indicate section and paragraph number} _____________________________________________
.

4. [I applicable] A completed Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA)
Affidavit, Florida Supreme Court Approved Family Law Form 12.902(d), is filed with this answer
as I disagree with the Affidavit filed by the Petitioner.

5. A completed Notice of Social Security Number, Florida Supreme Court Approved Family Law
Form 12.902(j), is filed with this answer if one has not already been filed in this case.

6. A completed Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form
12.902(b) or (c), ____ is, or ____ will be, filed.

Florida Supreme Court Approved Family Law Form 12.983(b), Answer to Petition to Determine Paternity and for
Related Relief (03/15)
- 757 -
I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand
delivered to the person(s) listed below on {date} .

Petitioner or his/her attorney:
Name:
Address:
City, State, Zip:
Fax Number:
Designated E-mail Address(es):__________________
_________________________________________

Florida Supreme Court Approved Family Law Form 12.983(b), Answer to Petition to Determine Paternity and for
Related Relief (03/15)
- 758 -
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
answer and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.

Dated:__________________________ ___________________________________________
Signature of Respondent
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es):__________________
__________________________________________
STATE OF FLORIDA
COUNTY OF __________________________

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

{Print, type, or stamp commissioned name of notary or
clerk.}
__ Personally known
__ Produced identification
Type of identification produced___________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent.
This form was completed with the assistance of:
{name of individual}_________________________________________________________________ ,
{name of business} __________________________________________________________________ ,
{address} ________________________________________________________ ,
{city} _____________, {state} ______, {zip code}_________, {telephone number} _________________.

Florida Supreme Court Approved Family Law Form 12.983(b), Answer to Petition to Determine Paternity and for
Related Relief (03/15)
- 759 -
INSTRUCTIONS FOR FLORIDA FAMILY LAW FORM
12.983(c),
ANSWER TO PETITION AND COUNTERPETITION TO DETERMINE
PATERNITY AND FOR RELATED RELIEF (03/15)

When should this form be used?

This form should be used when you are responding to a petition to determine paternity and asking the
court for something different than what was in the petition, such as parental responsibility, time-
sharing, and child support. The answer is used to admit or deny the allegations contained in the
petition, and the counterpetition is used to ask for whatever you want the court to do for you. The
other party has 20 days to answer your counterpetition after being served with your counterpetition.

IMPORTANT INFORMATION REGARDING E-FILING

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions for Florida Supreme Court Approved Family Law Form 12.983(c), Answer to Petition and
Counterpetition to Determine Paternity and for Related Relief (03/15)
- 760 -
Please CAREFULLY read the rules and instructions for: Certificate of Service (General), Florida Supreme
Court Approved Family Law Form 12.914; Designation of Current Mailing and E-mail Address, Florida
Supreme Court Approved Family Law Form 12.915; and Florida Rule of Judicial Administration 2.516.

What should I do next?

You have 20 days to file an answer or answer and counterpetition to the other party’s petition. A copy
of this form, along with all of the other forms required with this answer and counterpetition, must be
mailed or hand delivered to the other party in your case.

If you deny that the person named in the petition is the child(ren)’s father, a Motion for Scientific
Paternity Testing Florida Supreme Court Approved Family Law Form 12.983(e), should be filed. This is
used to ask the court to order a scientific test to determine who is the child(ren)’s father.

After you file an answer and counterpetition, the case will then generally proceed as follows:

UNCONTESTED. This case is uncontested if you and the other party agree on all issues raised in the
petition and the counterpetition. If this is the case, and you and the other party have complied with
mandatory disclosure and filed all of the required papers, either party may call the clerk, family law
intake staff, or judicial assistant to set a final hearing. If you request the hearing, you must notify the
other party of the hearing by using a Notice of Hearing (General), Florida Supreme Court Approved
Family Law Form 12.923, or other appropriate notice of hearing form.

CONTESTED. This case is contested if you and the other party disagree on any issues raised in the
petition or counterpetition. If you are unable to settle the disputed issues, either party may file a Notice
for Trial, Florida Supreme Court Approved Family Law Form 12.924, after you have complied with
mandatory disclosure and filed all of the required papers. Some circuits may require the completion of
mediation before a final hearing may be set. You should contact the clerk, family law intake staff, or
judicial assistant for instructions on how to set your case for trial (final hearing).

Where can I look for more information?

Before proceeding, you should read General Information for Self-Represented Litigants@ for some
basic information. The words that are in bold underline in these instructions are defined there. For
further information, see chapter 742, Florida Statutes.

Special notes...

If the child(ren)’s father signed papers at the hospital acknowledging that he was the father, paternity
was established as a matter of law. This should be indicated on page 2, section 10a of the
counterpetition part of this form. With this answer, you must file the following:

Instructions for Florida Supreme Court Approved Family Law Form 12.983(c), Answer to Petition and
Counterpetition to Determine Paternity and for Related Relief (03/15)
- 761 -
 Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida Supreme Court
Approved Family Law Form 12.902(d).
 Notice of Social Security Number Florida Supreme Court Approved Family Law Form 12.902(j).

 Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or (c). (This
must be filed within 45 days of service of the petition on you if not filed with this answer.)

 Certificate of Compliance with Mandatory Disclosure Florida Family Law Rules of Procedure Form
12.932. (This must be filed within 45 days of service of the petition on you, if not filed with this
answer, unless you and the other party have agreed not to exchange these documents.)

 Parenting Plan, Florida Supreme Court Approved Family Law Form 12.995(a), 12.995(b), or (c). If
the parents have reached an agreement, a signed and notarized Parenting Plan should be attached.
If the parents have not reached an agreement, a proposed Parenting Plan may be filed.

Many jurisdictions may require the completion of mediation before a final hearing may be set. A
parenting course must be completed prior to entry of the final judgment. You should contact the office
of your local clerk of court, family law intake staff, or the judicial assistant about requirements for
parenting courses or mediation where you live.

Parenting Plan and Time-Sharing. If the parties are unable to agree on parenting arrangements and a
time-sharing schedule, a judge will decide as part of establishing a Parenting Plan. The judge will decide
the parenting arrangements and time-sharing schedule based on the child(ren)’s best interests.
Regardless of whether there is an agreement between the parties, the court reserves jurisdiction to
modify issues relating to minor child(ren).

Listed below are some terms with which you should become familiar before completing your answer
and counterpetition. If you do not fully understand any of the terms below or their implications, you
should speak with an attorney before going any further.
Shared Parental Responsibility
Sole Parental Responsibility
Supervised Time-Sharing
No contact
Parenting Plan

Instructions for Florida Supreme Court Approved Family Law Form 12.983(c), Answer to Petition and
Counterpetition to Determine Paternity and for Related Relief (03/15)
- 762 -
Parenting Plan Recommendations
Time-Sharing Schedule

Parenting Plan. In all cases involving minor or dependent child(ren), a Parenting Plan shall be approved
or established by the court. If the parties have reached an agreement, you should file a Parenting Plan,
Florida Supreme Court Approved Family Law Form 12.995(a), 12.995(b), or 12.995(c) which addresses
the time-sharing schedule for the child(ren). If you have not reached an agreement, a proposed
Parenting Plan may be filed. A Parenting Plan will be established by the court.

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.983(c), Answer to Petition and
Counterpetition to Determine Paternity and for Related Relief (03/15)
- 763 -
IN THE CIRCUIT COURT OF THE ________________ JUDICIAL CIRCUIT,
IN AND FOR ______________________________ COUNTY, FLORIDA

Case No: ________________________
Division: ________________________

_________________________________,
Petitioner,
And

_________________________________,
Respondent.

ANSWER TO PETITION AND COUNTERPETITION
TO DETERMINE PATERNITY AND FOR RELATED RELIEF
I, {full legal name} , Respondent,
being sworn, certify that the following information is true:

ANSWER TO PETITION
1. I agree with Petitioner as to the allegations raised in the following numbered paragraphs in the
Petition and, therefore, admit those allegations: {indicate section and paragraph number}
__________________________________________________________________________________
_________________________________________________________________________________.

2. I disagree with Petitioner as to the allegations raised in the following numbered paragraphs in the
Petition and, therefore, deny those issues: {indicate section and paragraph number}
__________________________________________________________________________________
_________________________________________________________________________________.

3. I currently am unable to admit or deny the following paragraphs due to lack of information: {indicate
section and paragraph number} _______________________________________________________
_________________________________________________________________________________.

COUNTERPETITION TO DETERMINE PATERNITY
AND FOR RELATED RELIEF

SECTION I. PATERNITY
1. Respondent is the _____ mother _____ father of the following minor child(ren):
Name Birth Date
(1). _________________________________________________________________________

Florida Supreme Court Approved Family Law Form 12.983(c), Answer to Petition and Counterpetition to Determine
Paternity and for Related Relief (03/15)
- 764 -
(2). __________________________________________________________________________
(3). __________________________________________________________________________
(4). __________________________________________________________________________
(5). __________________________________________________________________________
(6). __________________________________________________________________________

2. Petitioner’s current address is: {street address, city, state}
______________________________________________________________________________
.

3. Respondent’s current address is: {street address, city, state}
______________________________________________________________________________
.

4. Both parties are over the age of 18.

5. Petitioner {Choose only one} _____ is _____ is not a member of the military service.

Respondent {Choose only one} _____is _____ is not a member of the military service.

6. Neither Petitioner nor Respondent is mentally incapacitated.

7. A completed Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida
Supreme Court Approved Family Law Form 12.902(d), is filed with this counterpetition.

8. A completed Notice of Social Security Number, Florida Supreme Court Approved Family Law
Form 12.902(j), is filed with this counterpetition.

9. A completed Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form
12.902(b) or (c), _____is, or_____ will be, filed.

10. Paternity Facts.
{Choose only one}
a. _____Paternity has previously been established as a matter of law.

b. _____ The parties engaged in sexual intercourse with each other in the month(s) of {list
month(s) and year(s)} __________________________________________________,
in: {city and state} _________________________________________________________.
As a result of the sexual intercourse, _____ Petitioner _____ Respondent conceived and
gave birth to the minor child(ren) named in paragraph 1. _____ Petitioner _____
Respondent is the natural father of the minor child(ren). The mother _____ was _____ was
not married at the time of the conception and/or birth of the minor child(ren) named in
paragraph l. If the mother was married, the name and address of her husband at the time
of conception and/or birth is:

Florida Supreme Court Approved Family Law Form 12.983(c), Answer to Petition and Counterpetition to Determine
Paternity and for Related Relief (03/15)
- 765 -
.

SECTION II. PARENTING PLAN ESTABLISHING PARENTAL RESPONSIBILITY AND TIME-SHARING
1. The minor child(ren) currently reside(s) with _____Mother _____ Father _____ Other: {explain}
.

2. Parental Responsibility. It is in the child(ren)’s best interests that parental responsibility be:
{Choose only one}
a. _____ shared by both Father and Mother.

3. Parenting Plan and Time-Sharing. It is in the best interests of the child(ren) that the family be
ordered to comply with a Parenting Plan that _____ includes _____ does not include parental
time-sharing with the child(ren). The Respondent states that it is in the best interests of the
child(ren) that:
{Choose only one}
a. _____The attached proposed Parenting Plan should be adopted by the court.
The parties ( ) have ( ) have not agreed to the Parenting Plan.

b. _____The court should establish a Parenting Plan with the following provisions:
1.____ No time-sharing for the _____ Father _____ Mother.
2.____ Limited time-sharing with the _____ Father _____ Mother.
3.____ Supervised time-sharing for the _____ Father _____ Mother
4.____ Supervised or third-party exchange for the child(ren).
5.____ Time-sharing schedule as follows:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.

4. Explain why this request is in the best interest of the child(ren):___________________________

Florida Supreme Court Approved Family Law Form 12.983(c), Answer to Petition and Counterpetition to Determine
Paternity and for Related Relief (03/15)
- 766 -
5. The minor child(ren) should:
[Choose only one]
a. _____ retain his/her (their) present name(s).

b. _____ receive a change of name as follows:

present name(s) be changed to:
1. 1.___________________________
2. 2.___________________________
3. 3.____________________________
4. __________________________ 4._____________________________
5. 5._____________________________
6. ___________________________ 6.____________________________

SECTION III. CHILD SUPPORT
[Indicate all that apply]
1. Respondent requests that the court award child support as determined by Florida’s child
support guidelines, section 61.30, Florida Statutes. A completed Child Support
Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e), is, or will
be, filed. Such support should be ordered retroactive to:
[Choose only one]
a. _____the date when the parents did not reside together in the same household with the
child, not to exceed a period of 24 months before the date of filing of this counterpetition.

b. _____the date of the filing of this petition.

c. _____other: {date} ____{Explain} _______________________________
____________________________________________________________________.

2. ______Respondent requests that the Court award a child support amount that is more
than or less than Florida’s child support guidelines. Respondent understands that a
Motion to Deviate from Child Support Guidelines, Florida Supreme Court Approved
Family Law Form 12.943, must be completed before the Court will consider this request.

3. ______Respondent requests that medical/dental insurance coverage for the minor
child(ren) be provided by:
[Choose only one]
a. _____Father.

Florida Supreme Court Approved Family Law Form 12.983(c), Answer to Petition and Counterpetition to Determine
Paternity and for Related Relief (03/15)
- 767 -
b. _____Mother.

4. _____Respondent requests that uninsured medical/dental expenses for the child(ren)
be paid by: [Choose only one]
a. _____Father.
b. _____Mother.
c. _____Father and Mother each pay one-half.
d. _____Father and Mother each pay according to the percentages in the Child Support
Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e).
e. _____Other {explain}:
_____________________________________
__________________________________________________________________________

5. _____Respondent requests that life insurance to secure child support be provided by:
[Choose only one]
a. _____Father.
b. _____Mother.
c. _____Both.

6. _____ Petitioner _____ Respondent _____ Both has (have) incurred medical expenses in
the amount of $ on behalf of the minor child(ren), including hospital and
other expenses incidental to the birth of the minor child(ren). There should be an
appropriate allocation or apportionment of these expenses.

7. _____ Petitioner _____ Respondent _____ Both has (have) received past public
assistance for this (these) minor child(ren).

RESPONDENT’S REQUEST
1. Respondent requests a hearing on this petition and understands that he or she must
attend the hearing.

2. Respondent requests that the Court enter an order that:
[Choose all that apply]
a. _____establishes paternity of the minor child(ren), ordering proper scientific testing, if
necessary;
b. _____establishes a Parenting Plan containing provisions for parental responsibility and time-
sharing for the minor or dependent child(ren);
c. _____awards child support, including medical/dental insurance coverage, for the minor
child(ren);
d. _____determines the appropriate allocation or apportionment of all expenses incidental to
the birth of the child(ren), including hospital and medical expenses;

Florida Supreme Court Approved Family Law Form 12.983(c), Answer to Petition and Counterpetition to Determine
Paternity and for Related Relief (03/15)
- 768 -
e. _____determines the appropriate allocation or apportionment of all other past, present,
and future medical and dental expenses incurred or to be incurred on behalf of the minor
child(ren);
f. _____changes the child(ren)’s name(s); and
g. _____other relief as follows:____________________________________________________

;
and grants such other relief as may be appropriate and in the best interests of the minor
child(ren).

I certify that a copy of this document was ( ) mailed ( ) faxed and mailed
( ) e-mailed ( ) hand-delivered to the person(s) listed below on {date}_________________________.

Petitioner or his/her attorney:
Name:__________________________
Address:_________________________
City, State, Zip:____________________
Fax Number:______________________
Designated E-mail Address(es):________

Dated:____________________ _____________________________________________
Signature of Respondent/Counterpetitioner
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es):____________________
_____________________________________________

STATE OF FLORIDA
COUNTY OF _____________________________

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

Florida Supreme Court Approved Family Law Form 12.983(c), Answer to Petition and Counterpetition to Determine
Paternity and for Related Relief (03/15)
- 769 -
{Print, type, or stamp commissioned name of notary or
clerk.}

__ Personally known
__ Produced identification
Type of identification produced__________________________________
IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks]This form was prepared for the Respondent/Counterpetitioner.
This form was completed with the assistance of:
{name of individual} _____________________________________________________________ ,
{name of business} _______________________________________________________________ ,
{address} _______________________________________________________________________ ,
{city} ___________,{state} _____, {zip code}___________, {telephone number} _______________.

Florida Supreme Court Approved Family Law Form 12.983(c), Answer to Petition and Counterpetition to Determine
Paternity and for Related Relief (03/15)
- 770 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.983(d),
ANSWER TO COUNTERPETITION (03/15)

When should this form be used?

This form may be used by a petitioner to respond to the respondent’s counterpetition in a paternity
case. You may use this form to admit or deny the allegations contained in the respondent’s
counterpetition.

IMPORTANT INFORMATION REGARDING E-FILING

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

To serve and receive documents by e-mail, you must designate your e-mail addresses by using the
Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family Law Form
12.915, and you must provide your e-mail address on each form on which your signature appears.
Please CAREFULLY read the rules and instructions for: Certificate of Service (General), Florida Supreme

Instructions for Florida Supreme Court Approved Family Law Form 12.983(d), Answer to Counterpetition
(03/15)
- 771 -
Court Approved Family Law Form 12.914; Designation of Current Mailing and E-mail Address, Florida
Supreme Court Approved Family Law Form 12.915; and Florida Rule of Judicial Administration 2.516.

What should I do next?

A copy of this form must be mailed, e-mailed, or hand-delivered to the other party in your case.

If the respondent has denied that the person named in the petition is the father of the child(ren) and
requested a scientific paternity test, you must now wait until the test is complete. You should then
proceed according to the instructions in Petition to Determine Paternity and for Related Relief, Florida
Supreme Court Approved Family Law Form 12.983(a).

Where can I look for more information?

Special notes...

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.983(d), Answer to Counterpetition
(03/15)
- 772 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
_____,
Petitioner/Counterrespondent,

and

_____,
Respondent/Counterpetitioner.

ANSWER TO COUNTERPETITION
I, {full legal name} ,
Petitioner/Counterrespondent, being sworn, certify that the following information is true:

l. I agree with Petitioner as to the allegations raised in the following numbered paragraphs in the
Petition and, therefore, admit those allegations: {indicate section and paragraph number} .

2. I disagree with Petitioner as to the allegations raised in the following numbered paragraphs in the
Petition and, therefore, deny those issues: {indicate section and paragraph number} .

3. I currently am unable to admit or deny the following paragraphs due to lack of information: {indicate
section and paragraph number} .

I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand
delivered to the person(s) listed below on {date} ______________________________________.

Respondent or his/her attorney:
Name:
Address:
City, State, Zip:
Fax Number:
Designated E-mail Address(es);____________________
_____________________________________________

Florida Supreme Court Approved Family Law Form 12.983(d), Answer to Counterpetition (03/15)
- 773 -
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this
answer and that the punishment for knowingly making a false statement includes fines and/or
imprisonment.

Dated:
Signature of Petitioner/Counterrespondent
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es):____________________
_____________________________________________

STATE OF FLORIDA
COUNTY OF

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

[Print, type, or stamp commissioned name of notary or
clerk.]
__ Personally known
__ Produced identification
Type of identification produced

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent.
This form was completed with the assistance of:
{name of individual} ___________________________________________________________________ ,
{name of business} _____________________________________________________________________,
{address} ____________________________________________ ,
{city} _______________,{state} ______, {zip code} _________, {telephone number} ________________.

Florida Supreme Court Approved Family Law Form 12.983(d), Answer to Counterpetition (03/15)
- 774 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.983(e),
MOTION FOR SCIENTIFIC PATERNITY TESTING (03/15)

When should this form be used?

This form should be used when the mother or alleged father wants the court to order a scientific
paternity test to determine the paternity of a minor child(ren).

IMPORTANT INFORMATION REGARDING E-FILING

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

To serve and receive documents by e-mail, you must designate your e-mail addresses by using the
Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family Law Form
12.915, and you must provide your e-mail address on each form on which your signature appears.
Please CAREFULLY read the rules and instructions for: Certificate of Service (General), Florida Supreme
Court Approved Family Law Form 12.914; Designation of Current Mailing and E-mail Address, Florida

Instructions for Florida Supreme Court Approved Family Law Form 12.983(e), Motion for Scientific Paternity
Testing (03/15)
- 775 -
Supreme Court Approved Family Law Form 12.915; and Florida Rule of Judicial Administration 2.516.

What should I do next?

When you have filed this motion, you are ready to set a hearing on this motion. You should check with
the clerk, family law intake staff, or judicial assistant for information on the local procedure for
scheduling a hearing. When you know the date and time of your hearing, you should file a Notice of
Hearing (General), Florida Supreme Court Approved Family Law Form 12.923, or other appropriate
notice of hearing form.

A copy of this motion and the Notice of Hearing must be mailed, e-mailed or hand-delivered to the
other party in your case.

Where can I look for more information?

Special notes...

These family law forms contain an Order on Motion for Scientific Paternity Testing, Florida Supreme
Court Approved Family Law Form 12.983(f), which the judge may use. You should check with the clerk,
family law intake staff, or judicial assistant to see if you need to bring it with you to the hearing. If so,
you should type or print the heading, including the circuit, county, case number, division, and the
parties’ names, and leave the rest blank for the judge to complete at your hearing or trial.

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.983(e), Motion for Scientific Paternity
Testing (03/15)
- 776 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
__,
Petitioner,

and

___,
Respondent.

MOTION FOR SCIENTIFIC PATERNITY TESTING
I, {choose only one} _____ Petitioner _____ Respondent certifies that the following information is true:
1. At this time, other than testimony, very little or no substantial proof of paternity or nonpaternity is
available in this action.
2. I request, under section 742.12, Florida Statutes, that the Court enter an order for appropriate
scientific testing of the biological samples of Petitioner and Respondent and the minor child(ren)
listed below, so that a determination of paternity of the minor child(ren) can be made to a
reasonable degree of medical certainty:
Name Birth Date
(1)
(2)
(3)
(4)
(5)
(6)

3. I request that the costs of the scientific testing initially be borne by ( ) Petitioner ( ) Respondent
( ) both Petitioner and Respondent.

I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand
delivered to the person(s) listed below on {date} .

_____ Petitioner or his/her attorney:
_____ Respondent or his/her attorney:
Name:
Address:
City, State, Zip: ______
Fax Number:

Florida Supreme Court Approved Family Law Form 12.983(e), Motion for Scientific Paternity Testing (03/15)
- 777 -
Designated E-mail Address(es):______________________
________________________________________________

Signature of Party
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es):____________________
_____________________________________________

STATE OF FLORIDA
COUNTY OF

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

[Print, type, or stamp commissioned name of notary or
clerk.]
__ Personally known
__ Produced identification
Type of identification produced

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent.
This form was completed with the assistance of:
{name of individual} ___________________________________________________________________ ,
{name of business} __________________________________________________________________ ,
{address} _____________________________________________,
{city} _______________,{state} ______,{zip code}____________, {telephone number} .

Florida Supreme Court Approved Family Law Form 12.983(e), Motion for Scientific Paternity Testing (03/15)
- 778 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
__,
Petitioner,

and

___,
Respondent.

ORDER ON MOTION FOR SCIENTIFIC PATERNITY TESTING
This cause having come to be heard on {date} __________, upon a motion/stipulation
for scientific paternity testing, and the Court having been fully advised in the premises, it is therefore
FOUND:

1. That the Court has jurisdiction over the parties and subject matter of this action.

2. {choose one only}
a._____That the natural mother of the dependent child(ren) at issue was not married to any
individual at the time of conception or birth of the child(ren).
b. _____ That the natural mother of the dependent child(ren) at issue was married to an individual
other than the alleged father at the time of conception or birth of said child(ren); however, a court
order has determined that said individual is not the child(ren)’s father.

It is therefore ORDERED:

3. The above motion is GRANTED.

4. Petitioner, Respondent, and the minor child(ren) shall appear for the purpose of appropriate
scientific paternity testing:
{choose one only}
a. _____immediately.
b. _____at a.m./p.m. on {date} at {location} ______________________
________________________________________________________________________________ .
c. _____ at a time and place to be specified by the Florida Department of Revenue. Appropriate
scientific paternity testing on Petitioner, Respondent, and the minor child(ren) shall be in {city}
, Florida, with at least 30 days advance written notice. If the Florida
Department of Revenue fails to notify the party(ies), the party(ies) shall contact the Florida
Department of Revenue for further instructions.

Florida Supreme Court Approved Family Law Form 12.983(f), Order on Motion for Scientific Paternity Testing
(03/15)
- 779 -
5. The costs of the scientific paternity testing shall be assessed ( ) at a later date ( ) against
Petitioner ( ) against Respondent ( ) Other {explain} .

6. The test results, together with the opinions and conclusions of the test laboratory, shall be filed with
the Court. Any objection to the test results must be made in writing and must be filed with the
Court at least 10 days before the hearing. If no objection is filed, the test results shall be admitted
into evidence with no further predicate. Nothing in this paragraph prohibits a party from calling an
outside expert witness to refute or support the testing procedure or results or the mathematical
theory on which they are based.

7. Test results are admissible in evidence and should be weighed along with other evidence of the
paternity of the alleged father unless the statistical probability of paternity equals or exceeds 95
percent. A statistical probability of 95 percent or more creates a rebuttable presumption that the
alleged father is the biological father of the child(ren). If the party fails to rebut the presumption of
paternity, the Court may enter a summary judgment of paternity. If the test results show the alleged
father cannot be the biological father, the case shall be dismissed with prejudice.

8. The Court reserves jurisdiction over the parties and the subject matter of this action to enforce the
terms and provisions of this and all previous orders as well as to enter such other orders as may be
just.

DONE AND ORDERED on , in ___________________________, Florida.

CIRCUIT JUDGE

I CERTIFY that a copy of {name of document(s)}_______________________ was ( ) mailed ( ) faxed
and mailed ( ) e-mailed ( ) hand-delivered to the parties and any other person(s) or entities listed
below on {date} ________________________________________.

CLERK OF THE CIRCUIT COURT
(SEAL)
By:
Deputy Clerk or Judicial Assistant
Petitioner (or his or her attorney)
Respondent (or his or her attorney)
Other: ________________________

Florida Supreme Court Approved Family Law Form 12.983(f), Order on Motion for Scientific Paternity Testing
(03/15)
- 780 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
,
Petitioner,
and

,
Respondent.

FINAL JUDGMENT OF PATERNITY

This cause came before the Court upon a Petition to Determine Paternity and for Related Relief, under
chapter 742, Florida Statutes. The Court having reviewed the file and having heard the testimony,
makes these findings of fact and reaches these conclusions of law:

1. The Court has jurisdiction of the subject matter and the parties.

2. Paternity. {Choose only one} _____ By operation of law, _____ The Court finds that
{full legal name} ,
is the natural and biological father of the minor child(ren), listed below:
The parties’ dependent or minor child(ren) is (are):
Name Birth date

SECTION I. PARENTAL RESPONSIBILITY AND PARENTING PLAN ESTABLISHING TIME-SHARING WITH
DEPENDENT OR MINOR CHILD(REN)

1. Jurisdiction. The Court has jurisdiction to determine parental responsibility and to adopt or
establish a Parenting Plan with time-sharing with regard to the child(ren) listed in paragraph 2
above.

2. Parental Responsibility and Parenting Plan for the Minor Child(ren).
{Choose only one}
a. _____Not adjudicated. Since no request for relief was made in this action, parental

Florida Supreme Court Approved Family Law Form 12.983(g), Final Judgment of Paternity (03/15)
- 781 -
responsibility of and time-sharing with the minor child(ren) is governed by sections 742.031
and 744.301, Florida Statutes.

Florida Supreme Court Approved Family Law Form 12.983(g), Final Judgment of Paternity (03/15)
- 782 -
b. _____Parenting Plan. The parties shall comply with the Parenting Plan which is attached
hereto and incorporated herein as Exhibit _____.

SECTION II. CHILD SUPPORT
1. The Court finds that there is a need for child support and that the _____ Mother _____ Father
(hereinafter Obligor) has the present ability to pay child support. The amounts in the Child
Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e), filed by
the _____ Mother _____ Father are correct OR the Court makes the following findings:

The Mother’s net monthly income is $ _ , (Child Support Guidelines ____%).
The Father’s net monthly income is $ __, (Child Support Guidelines ____%).
Monthly child care costs are $ __ .
Monthly health/dental insurance costs are $ __.

2. Amount.
Child support established at the rate of $___________per month for the _______children {total
number of parties’ minor or dependent children} shall be paid commencing _________________
{month, day, year} and terminating ___________________ {month, day, year}. Child support
shall be paid in the amount of $___________per ___________ {week, month, other} which is
consistent with the Obligor’s current payroll cycle.

Upon the termination of the obligation of child support for one of the parties’ oldest children,
child support in the amount of $__________for the remaining _____children {total number of
remaining children} shall be paid commencing __________________________ {month, day,
year} and terminating____________________________{month, day, year}. This child support
shall be paid in the amount of $__________ per ___________ {week, month, other} consistent
with Obligor’s current payroll cycle.

{Insert schedule for the child support obligation, including the amount, and commencement
and termination dates, for the remaining minor or dependent children, which shall be payable
as the obligation for each child ceases. Please indicate whether the schedule ____appears
below or ____ is attached as part of this form.}
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

The Obligor shall pay child support until all of the minor or dependent children: reach the age of
18; become emancipated, marry, join the armed services, die, or become self-supporting; or
until further order of the court or agreement of the parties. The child support obligation shall
continue beyond the age of 18 and until high school graduation for any child who is dependent
in fact, between the ages of 18 and 19, and is still in high school, performing in good faith with a
reasonable expectation of graduation before the age of 19.
If the child support ordered deviates from the guidelines by more than 5%, the factual findings
which support that deviation are:

Florida Supreme Court Approved Family Law Form 12.983(g), Final Judgment of Paternity (03/15)
- 783 -
3. Arrearage/Retroactive Child Support.

a. ____There is no retroactive child support or arrearage at the time of this Final Judgment.

b. ____ The _____ Mother _____ Father _____ both has (have) incurred medical expenses in
the amount of $ on behalf of the minor child(ren), including hospital and other
expenses incidental to the birth of the minor child(ren). Petitioner shall pay ___%,
Respondent shall pay __%, which shall be paid as follows: _____ added to arrearage in
paragraph c below _____ other {explain} _______
__________________________________________________________________________

c. ____The _____Mother _____ Father shall pay to the other party the child support arrearage
of:
$________ for retroactive child support, as of {date}______________________________ .
$ for previously ordered unpaid child support, as of {date} _________________ .
$ for previously incurred medical expenses.
The total of $ in child support arrearage shall be repaid at the rate of $_____
per month, payable ( ) in accordance with Obligor’s employer’s payroll cycle, and in any
event at least once a month ( ) other {explain} ___________________________________
___________________________________________________________________________,
beginning {date} ________________________, until paid in full including statutory interest.

4. Insurance.
{Indicate all that apply}
a. _____ Health/Dental Insurance. ____ Mother _____ Father shall be required to maintain:
_____ health and/or _____ dental insurance for the parties’ minor child(ren), so long as
it is reasonable in cost and accessible to the child(ren). The party providing insurance
shall be required to convey insurance cards demonstrating said coverage to the other
party;
OR
_____ health _____ dental insurance is not reasonable in cost or accessible to the
child(ren) at this time.

b. _____ Reasonable and necessary uninsured medical/dental/prescription drug costs for the
minor child(ren) shall be assessed as follows:
_____ Shared equally by both parents.
_____ Prorated according to the child support guideline percentages.
_____ Other {explain}: _______________________________________________________
__________________________________________________________________________
As to these uninsured medical/dental/prescription drug expenses, the party who incurs the
expense shall submit request for reimbursement to the other party within 30 days, and the
other party, within 30 days of receipt, shall submit the applicable reimbursement for that
expense, according to the schedule of reimbursement set out in this paragraph.

5. _____Life Insurance (to secure payment of support). To secure the child support obligations in

Florida Supreme Court Approved Family Law Form 12.983(g), Final Judgment of Paternity (03/15)
- 784 -
this judgment, _____ Mother _____ Father _____ each party shall maintain life insurance
coverage, in an amount of at least $ _, on _____ his life _____ her life _____ his/her
life naming the _____ minor child(ren) as the beneficiary(ies) OR naming the _____ Mother
_____Father _____other {name} _________________________________________as Trustee
for the minor child(ren), so long as reasonably available. The obligation to maintain the life
insurance coverage shall continue until the youngest child turns 18, becomes emancipated,
marries, joins the armed services, dies, or otherwise becomes self-supporting.

6. _____IRS Income Tax Exemption(s). The assignment of any tax exemption(s) for the child(ren)
shall be as follows: _____________________
.
Further, each party shall execute any and all IRS forms necessary to effectuate the provisions of
this paragraph.

7. Other provisions relating to child support: ___________________________________________

SECTION III. METHOD OF PAYMENT

Obligor shall pay court-ordered child support/alimony and arrears, if any, as follows:

1. Place of Payment

a. ____Obligor shall pay court-ordered support directly to either the State Disbursement Unit,
or the central depository, as required by statute, along with any fee required by statute.
OR
b. ____Both parties have requested and the court finds that it is in the best interests of the
child(ren) that support payments need not be directed through either the State
Disbursement Unit or the central depository at this time; however, either party may
subsequently apply, pursuant to section 61.13(1)(d)3, Florida Statutes, to require payments
through either the State Disbursement Unit or the central depository.

2. Income Deduction.

a. ____Immediate. Obligor shall pay through income deduction, pursuant to a separate
Income Deduction Order which shall be effective immediately. Obligor is individually
responsible for paying this support obligation until all of said support is deducted from
Obligor’s income. Until support payments are deducted from Obligor’s paycheck, Obligor is
responsible for making timely payments directly to the State Disbursement Unit or the
Obligee, as previously set forth in this order.

b. ____Deferred. Income deduction is ordered this day, but it shall not be effective until a
delinquency of $ , or, if not specified, an amount equal to one month’s obligation
occurs. Income deduction is not being implemented immediately based on the following
findings: Income deduction is not in the best interests of the child(ren) because: {explain}

Florida Supreme Court Approved Family Law Form 12.983(g), Final Judgment of Paternity (03/15)
- 785 -
AND
there is proof of timely payment of a previously ordered obligation without an income
deduction order in cases of modification,
AND
_____ there is an agreement by the Obligor to advise the Title IV-D agency, the clerk of
court, and the Obligee of any change in Payor and/or health insurance
OR
_____ there is a signed written agreement providing an alternative arrangement between
the Obligor and the Obligee and, at the option of the IV-D agency, by the IV-D agency in IV-D
cases in which there is an assignment of support rights to the state, reviewed and entered in
the record by the court.

3. Bonus/one-time payments. _____ All _____% _____ No income paid in the form of a bonus or
other similar one-time payment, up to the amount of any arrearage or the remaining balance
thereof owed pursuant to this order, shall be forwarded to Obligee pursuant to the payment
method prescribed above.

4. Other provisions relating to method of payment. ________________________________

SECTION IV. CHILD(REN)’S NAME(S)
a. _____There shall be no change to the child(ren)’s name(s).

b. _____It is in the child(ren)’s best interests that
the child(ren)’s present name(s): shall be changed to the following:

(1) _______________________________ (1) ______________________________
(2) ________________________________ (2) _______________________________
(3) ________________________________ (3) _______________________________
(4) ________________________________ (4) _______________________________
(5) ________________________________ (5) _______________________________
(6) ________________________________ (6) _______________________________
by which they shall hereafter be known

c. The name change is in the best interest(s) of the child(ren) because:__________________
________________________________________________________________________
_________________________________________________________________________ .
SECTION V. ATTORNEY’S FEES, COSTS, AND SUIT MONEY
1. _____ Petitioner’s _____ Respondent’s request(s) for attorney’s fees, costs, and suit money is
(are) denied because
.

2. ____The Court finds there is a need for and an ability to pay attorney’s fees, costs, and suit
money. _____ Petitioner _____ Respondent is hereby ordered to pay to the other party
$ __ in attorney’s fees, and $ ____ in costs. The Court further finds that the
attorney’s fees awarded are based on the reasonable rate of $ per hour and

Florida Supreme Court Approved Family Law Form 12.983(g), Final Judgment of Paternity (03/15)
- 786 -
reasonable hours. Other provisions relating to attorney’s fees, costs, and suit money
are as follows:___________________________________________________________________
______________________
.

3. The costs of the scientific paternity testing shall be assessed:
_____ against Petitioner
_____ against Respondent
_____ Other {explain} .

SECTION VI. OTHER PROVISIONS

1. Other Provisions.

The Court reserves jurisdiction to modify and enforce this Final Judgment.

DONE AND ORDERED at _____________________, Florida, on .

CIRCUIT JUDGE

I CERTIFY that a copy of this {name of document}__________________________________________ was
( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the parties or entities listed
below on {date} ____________________________.

(SEAL)

By:
{Clerk of court or designee}

Florida Supreme Court Approved Family Law Form 12.983(g), Final Judgment of Paternity (03/15)
- 787 -
Petitioner (or his or her attorney)
Respondent (or his or her attorney)
Central depository
State Disbursement Unit
_ Other: _______________________________________

Florida Supreme Court Approved Family Law Form 12.983(g), Final Judgment of Paternity (03/15)
- 788 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:

,
Husband,

and

,
Wife.

FINAL JUDGMENT OF DISSOLUTION OF MARRIAGE WITH MINOR
CHILD(REN) (UNCONTESTED)
This cause came before this Court for a hearing on a Petition for Dissolution of Marriage. The Court,
having reviewed the file and heard the testimony, makes these findings of fact and reaches these
conclusions of law:

1. The Court has jurisdiction over the subject matter and the parties.

2. At least one party has been a resident of the State of Florida for more than 6 months immediately
before filing the Petition for Dissolution of Marriage.

3. The marriage between the parties is irretrievably broken. Therefore, the marriage between the
parties is dissolved, and the parties are restored to the status of being single.

4. Marital Settlement Agreement. The parties have voluntarily entered into a Marital Settlement
Agreement and Parenting Plan, and each party has filed the required Family Law Financial Affidavit.
Therefore, the Marital Settlement Agreement and Parenting Plan is filed as Exhibit A in this case and
is ratified and made a part of this final judgment. The parties are ordered to obey all of the
provisions.

5. The Court finds that the parties have the present ability to pay support as agreed to in the marital
settlement agreement as ratified and made part of this final judgment.

6. {If applicable} The wife’s former name of {full legal name} ____________________
_____________is restored.

7. The Court reserves jurisdiction to modify and enforce this final judgment.

Florida Supreme Court Approved Family Law Form 12.990(b)(1), Final Judgment of Dissolution of Marriage with
Minor Child(ren) (Uncontested) (03/15)
- 789 -
Florida Supreme Court Approved Family Law Form 12.990(b)(1), Final Judgment of Dissolution of Marriage with
Minor Child(ren) (Uncontested) (03/15)
- 790 -
DONE AND ORDERED at ___________________________, Florida, on .

CIRCUIT JUDGE

I certify that a copy of the {name of document(s)} __________________________________________
was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the parties and any
entities listed below on {date}________________________________.

by__________________________________
{Clerk of court or designee}

Petitioner (or his or her attorney)
Respondent (or his or her attorney)
Other:

Florida Supreme Court Approved Family Law Form 12.990(b)(1), Final Judgment of Dissolution of Marriage with
Minor Child(ren) (Uncontested) (03/15)
- 791 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
,
Husband,

and

,
Wife.

FINAL JUDGMENT OF DISSOLUTION OF MARRIAGE WITH
PROPERTY BUT NO DEPENDENT OR MINOR CHILD(REN)
(UNCONTESTED)

This cause came before this Court for a hearing on a Petition for Dissolution of Marriage. The Court,
having reviewed the file and heard the testimony, makes these findings of fact and reaches these
conclusions of law:

1. The Court has jurisdiction over the subject matter and the parties.
2. At least one party has been a resident of the State of Florida for more than 6 months
immediately before filing the Petition for Dissolution of Marriage.
3. The parties have no minor or dependent children in common, and the wife is not pregnant.
4. The marriage between the parties is irretrievably broken. Therefore, the marriage between the
parties is dissolved, and the parties are restored to the status of being single.
5. Marital Settlement Agreement. The parties have voluntarily entered into a Marital Settlement
Agreement, and each has filed the required Family Law Financial Affidavit. Therefore, the
Marital Settlement Agreement is filed as Exhibit _____ in this case and is ratified and made a
part of this final judgment. The parties are ordered to obey all of its provisions.
6. The Court finds that the parties have the present ability to pay support as agreed to in the
marital settlement agreement as ratified and made part of this final judgment.
7. {If applicable} The wife’s former name of {full legal name}
_____________ is restored.
8. The Court reserves jurisdiction to enforce this final judgment.

Florida Supreme Court Approved Family Law Form 12.990(b)(2), Final Judgment of Dissolution of Marriage with
Property but No Dependent or Minor Child(ren) (Uncontested) (03/15)
- 792 -
DONE AND ORDERED in ____________________________, Florida. on __.

CIRCUIT JUDGE

I certify that a copy of {name of document(s)} ________________________________________________
was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the parties listed below on
{date}___________________.

by__________________________________
{Clerk of court or designee}

Petitioner (or his or her attorney)
Respondent (or his or her attorney)
Other:

Florida Supreme Court Approved Family Law Form 12.990(b)(2), Final Judgment of Dissolution of Marriage with
Property but No Dependent or Minor Child(ren) (Uncontested) (03/15)
- 793 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
,
Husband,

and

,
Wife.

FINAL JUDGMENT OF DISSOLUTION OF MARRIAGE WITH
NO PROPERTY OR DEPENDENT OR MINOR CHILD(REN) (UNCONTESTED)

1. The Court has jurisdiction over the subject matter and the parties.
2. At least one party has been a resident of the State of Florida for more than 6 months
immediately before filing the Petition for Dissolution of Marriage.
3. The parties have no minor or dependent children in common, and the wife is not pregnant.
4. The marriage between the parties is irretrievably broken. Therefore, the marriage between the
parties is dissolved, and the parties are restored to the status of being single.
5. There is no marital property or marital debts to divide, as the parties have previously divided all
of their personal property. Therefore, each is awarded the personal property he or she
presently has in his or her possession. Each party shall be responsible for any debts in his or her
own name.
6. {If applicable} The wife’s former name of {full legal name}
is restored.

7. The Court reserves jurisdiction to enforce this judgment.

DONE AND ORDERED in_______________________, Florida, on .

Florida Supreme Court Approved Family Law Form 12.990(b)(3), Final Judgment of Dissolution of Marriage with No
Property or Minor Child(ren) (Uncontested) (03/15)
- 794 -
CIRCUIT JUDGE

by__________________________________
{Clerk of court or designee}

Petitioner (or his or her attorney)
Respondent (or his or her attorney)
Other:

Florida Supreme Court Approved Family Law Form 12.990(b)(3), Final Judgment of Dissolution of Marriage with No
Property or Minor Child(ren) (Uncontested) (03/15)
- 795 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:______________________________
Division: ______________________________

In re the Marriage of:

,
Husband,

and

,
Wife.

FINAL JUDGMENT OF DISSOLUTION OF MARRIAGE
WITH DEPENDENT OR MINOR CHILD(REN)
This cause came before this Court for a trial on a Petition for Dissolution of Marriage. The Court, having
reviewed the file and heard the testimony, makes these findings of fact and reaches these conclusions of
law:

SECTION I. MARITAL ASSETS AND LIABILITIES
A. Date of Valuation of Property. The assets and liabilities listed below are divided as indicated. The
date of valuation of these assets and liabilities is, unless otherwise indicated:
a. ____ date of filing petition for dissolution of marriage.
b. ____ date of separation.
c. ____ date of final hearing.
d. ____ other: {specify date}_____________________________________________

B. Division of Assets.
1. The assets listed below are nonmarital assets. Each party shall keep, as his or her own, the

Florida Supreme Court Approved Family Law Form 12.990(c)(1), Final Judgment of Dissolution of Marriage with
Dependent or Minor Child(ren) (03/15)
- 796 -
assets found to be nonmarital, and the other party shall have no further rights or responsibilities
regarding these assets.

Current Wife’s Husband’s
ASSETS: DESCRIPTION OF ITEM(S) Fair Non- Non-
Please describe each item as clearly as possible. Market marital Marital
You do not need to list account numbers. Value Property Property
$ $ $

$ $ $
Total Nonmarital Assets

2. The assets listed below are marital assets. Each party shall keep, as his or her own, the assets
awarded in this section, and the other party shall have no further rights or responsibilities regarding
these assets. Any personal item(s) not listed below are awarded to the party currently in
possession or control of the item(s).

Current
ASSETS: DESCRIPTION OF ITEM(S) Fair Wife Husband
Please describe each item as clearly as possible. Market Shall Shall
You do not need to list account numbers. Value Receive Receive
Cash (on hand or in banks/credit unions) $ $ $

Stocks/bonds

Notes
Business interests

Real estate: (Home)

Automobiles

Florida Supreme Court Approved Family Law Form 12.990(c)(1), Final Judgment of Dissolution of Marriage with
Dependent or Minor Child(ren) (03/15)
- 797 -
Current
ASSETS: DESCRIPTION OF ITEM(S) Fair Wife Husband
Please describe each item as clearly as possible. Market Shall Shall
You do not need to list account numbers. Value Receive Receive
Boats
Furniture & furnishings

Jewelry

Life Insurance (cash surrender value)
Retirement Plans (Profit sharing, Pension, IRA, 401(k)(s), etc.)

Other assets

Total Marital Assets $ $ $

C. Division of Liabilities/Debts.
1. The liabilities listed below are nonmarital liabilities and, therefore, are owed as indicated. Each
party shall owe, as his or her own, the liabilities found to be nonmarital, and the other party
shall have no responsibilities regarding these debts.
Wife’s Husband’s
LIABILITIES: DESCRIPTION OF DEBTS Current Non- Non-
Please describe each item as clearly as possible. Amount Marital Marital
You do not need to list account numbers. Owed Liability Liability

Florida Supreme Court Approved Family Law Form 12.990(c)(1), Final Judgment of Dissolution of Marriage with
Dependent or Minor Child(ren) (03/15)
- 798 -
Wife’s Husband’s
LIABILITIES: DESCRIPTION OF DEBTS Current Non- Non-
Please describe each item as clearly as possible. Amount Marital Marital
You do not need to list account numbers. Owed Liability Liability
$ $ $

Total Nonmarital Liabilities $ $ $

2. The liabilities listed below are marital liabilities and are divided as indicated. Each party shall
hold the other party harmless and pay, as his or her own, the marital liabilities awarded below.

LIABILITIES: DESCRIPTION OF DEBTS Current
Please describe each item as clearly as possible. Amount Wife Husband
You do not need to list account numbers. Owed Shall Pay Shall Pay
Mortgages on real estate: (Home) $ $ $
(Other)
Charge/Credit card accounts

Auto loan
Auto loan
Bank. Credit Union loans

Other

Florida Supreme Court Approved Family Law Form 12.990(c)(1), Final Judgment of Dissolution of Marriage with
Dependent or Minor Child(ren) (03/15)
- 799 -
LIABILITIES: DESCRIPTION OF DEBTS Current
Please describe each item as clearly as possible. Amount Wife Husband
You do not need to list account numbers. Owed Shall Pay Shall Pay

Total Marital Liabilities
$ $ $

D. Contingent assets and liabilities will be divided as follows: _________________________________
________________________________________________________________________________
________________________________________________________________________________.

E. The distribution of assets and liabilities in this final judgment is equitable; if each party does not
receive approximately one-half, the distribution is based on the following facts and reasoning:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

F. Beneficiary Designation (By completing this section, the beneficiary designations continue after
entry of Final Judgment of Dissolution of Marriage.)

The designation providing for the payment or transfer at death of an interest in the assets described
below to or for the benefit of the deceased party’s former spouse is NOT VOID as of the date of entry of
the Final Judgment of Dissolution of Marriage.

The Final Judgment of Dissolution of Marriage shall provide that the designations set forth below remain
in full force and effect:

_____1. The _____Husband _____Wife shall acquire or maintain the following assets for the benefit of
the other spouse or child(ren), to be paid upon his/her death outright or in trust. This provision only
applies if other assets fulfilling such requirement for the benefit of the other spouse or child(ren) do not
exist upon his/her death and unless precluded by statute. {Describe the assets with specificity}:_______
________________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ .

Florida Supreme Court Approved Family Law Form 12.990(c)(1), Final Judgment of Dissolution of Marriage with
Dependent or Minor Child(ren) (03/15)
- 800 -
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________ .

SECTION II. EXCLUSIVE USE AND POSSESSION OF HOME
{Indicate all that apply}
1. The____ Husband ____ Wife, as a condition of support, shall have exclusive use and possession of
the dwelling located at the following address:______________________
_______________________________________________________________________________
until: {date or event} ______________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________ .

2. The___ _ Husband ____ Wife may make visits to the premises described in the paragraph above for
the purpose of obtaining any items awarded in this Final Judgment. These visits shall occur after
notice to the person granted exclusive use and possession of the dwelling and at the earliest
convenience of both parties or as ordered in paragraph 4 below.

3. ____Upon the termination of the right of exclusive use and possession, the dwelling shall be sold
and the net proceeds divided _% to Husband and _% to Wife, with the following credits
and/or setoffs being allowed: _____________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

4. ____Other: ______________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

SECTION III. PARENTING PLAN ESTABLISHING PARENTAL RESPONSIBILITY AND TIME-SHARING WITH
DEPENDENT OR MINOR CHILD(REN)
1. Jurisdiction. The Court has jurisdiction to determine parental responsibility, to establish or adopt a
Parenting Plan, and a time-sharing schedule with regard to the minor child(ren) listed in paragraph 2
below.

Florida Supreme Court Approved Family Law Form 12.990(c)(1), Final Judgment of Dissolution of Marriage with
Dependent or Minor Child(ren) (03/15)
- 801 -
______________________________________________________________________________
______________________________________________________________________________

3. Parenting Plan. The parties shall comply with the Parenting Plan which is attached and incorporated
herein as Exhibit _____.

SECTION IV. ALIMONY
1. _____ The Court denies the request(s) for alimony;
OR
2. _____ The Court finds that ____ Husband ____ Wife, (hereinafter Obligee), has an actual need
for, and that ____ Husband ____ Wife (hereinafter Obligor) has the present ability to pay,
alimony as follows: {Indicate all that apply}

a. Permanent Periodic.

1. The Court finds that no other form of alimony is fair and reasonable under the
circumstances of the parties.

2. As a marriage of: {Choose only one}

_______ Long Duration (17 years or greater) alimony is appropriate upon consideration
of all relevant factors;

_______Moderate Duration (greater than 7 years but less than 17) alimony is
appropriate based upon clear and convincing evidence after consideration of all relevant
factors; or

_______Short Duration (less than 7 years) alimony is appropriate based upon the
following exceptional circumstances:___________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________.

3. Obligor shall pay permanent periodic alimony to Obligee in the amount of $ _
per month, payable _____ in accordance with Obligor’s employer’s payroll cycle, and in
any event, at least once a month _____ other {explain}
_____________________________________________________________________

______________________________________________________________________
beginning {date} ___________________. This alimony shall continue until modified by

Florida Supreme Court Approved Family Law Form 12.990(c)(1), Final Judgment of Dissolution of Marriage with
Dependent or Minor Child(ren) (03/15)
- 802 -
court order, the death of either party, or remarriage of Obligee, whichever occurs first.
The alimony may be modified or terminated based upon either a substantial change in
circumstances, or the existence of a supportive relationship in accordance with section
61.14, Florida Statutes.

b._____ Bridge-the-Gap. Obligor shall pay bridge-the-gap alimony to Obligee in the amount of
$________per month, payable _____ in accordance with Obligor’s employer’s payroll cycle, and
in any event, at least once a month or _____ other {explain}______________________________
beginning {date}_____________________and continuing until: {date}______________________
{a period not to exceed two (2) years}; death of either party; or remarriage of the Obligee,
whichever occurs first.

c.______Rehabilitative. Obligor shall pay rehabilitative alimony to Obligee in the amount of
$__________ per month, payable _____ in accordance with Obligor’s employer’s payroll cycle,
and in any event, at least once a month or _____ other {explain}__________________________
beginning {date}___________________. This rehabilitative alimony shall continue until:
modified by court order; the death of either party; or until {date/event} ___________________
______________________________________________________________________________,
whichever occurs first. The rehabilitative plan presented demonstrated the following: ________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.

d._____Durational. Obligor shall pay durational alimony to Obligee in the amount of $_______
per month payable _____ in accordance with Obligor’s employer’s payroll cycle, and in any
event, at least once a month _____ other {explain}_____________________________________
beginning {date}_____________________and terminating on {date}______________________,
the death of either party, remarriage of the Obligee, or until modified by court order in
accordance with section 61.08(7), Florida Statutes, whichever occurs first.

e._____Lump Sum. Obligor shall pay lump sum alimony to Obligee in the amount of $________,
which shall be paid as follows:_____________________________________________________
______________________________________________________________________________.

f. _____Retroactive. Obligor shall pay retroactive alimony in the amount of $ for the
period of {date}_______________,through {date} __________________, which shall be paid
pursuant to paragraph 4 below.

Florida Supreme Court Approved Family Law Form 12.990(c)(1), Final Judgment of Dissolution of Marriage with
Dependent or Minor Child(ren) (03/15)
- 803 -
d. The financial resources of each party, including the nonmarital and marital assets and
liabilities distributed to each;
e. The earning capacities, educational levels, vocational skills, and employability of the parties
and, when applicable, the time necessary for either party to acquire sufficient education or
training to enable such party to find appropriate employment;
f. The contribution of each party to the marriage, including, but not limited to, services
rendered homemaking, child care, education, and career building of the other party;
g. The responsibilities each party will have with regard to any minor or dependent children
they have in common;
h. The tax treatment and consequences to both parties of any alimony award, including the
designation of all or a portion of the payment as a nontaxable, nondeductible payment;
i. All sources of income available to either party, including income available to either party
through investments of any asset held by that party and
j. Any other factor necessary to do equity and justice between the parties: {explain}
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.
_______ Please indicate here if additional pages are attached.

4. Arrearage/Retroactive Alimony.
a.____There is no alimony arrearage at the time of this Final Judgment.
OR
b. _____The _____ Husband _____ Wife shall pay to the other spouse the alimony arrearage of:
$ ___ for retroactive alimony, as of {date}_______________________;
$ ___ for previously ordered unpaid alimony, as of {date} _________________.
The total of $ ________ in alimony arrearage shall be repaid in the amount of $ _ ___ per
month, payable _____ in accordance with Obligor’s employer’s payroll cycle, and in any event at
least once a month or _____ other {explain} _________________________________________
______________________________________________________________________________
______________________________________________________________________________
beginning {date}____________________________, until paid in full including statutory interest.

5. ____ Life Insurance (to secure payment of support). To secure the alimony obligations set forth
in this judgment, Obligor shall maintain life insurance on his/her life naming Obligee as the
sole irrevocable beneficiary, so long as reasonably available. This insurance shall be in the
amount of at least $___________ and shall remain in effect until the obligation for alimony
terminates.

6. ____Other provisions relating to alimony, including any tax treatment and consequences:
a. The award of alimony _____ does not _____ does leave the Obligor with significantly

Florida Supreme Court Approved Family Law Form 12.990(c)(1), Final Judgment of Dissolution of Marriage with
Dependent or Minor Child(ren) (03/15)
- 804 -
less net income than the net income of the recipient/Obligee. If the award does leave
the Obligor with significantly less net income than that of the Obligee, the Court finds
the following exceptional circumstances:
_________________________________________________________________
_________________________________________________________________
__________________________________________________________________ .

b. Other_____________________________________________________________
__________________________________________________________________
__________________________________________________________________ .

SECTION V. CHILD SUPPORT

1. _____The Court finds that there is a need for child support and that the _____ Wife _____ Husband
(hereinafter Obligor) has the present ability to pay child support. The amounts in the Child Support
Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e), filed by the
____ Wife ____ Husband are correct;
OR
_____The Court makes the following findings:
The Wife’s net monthly income is $ __, (Child Support Guidelines ____%).
The Husband’s net monthly income is $ __, (Child Support Guidelines ____%).
Monthly child care costs are $ _____.
Monthly health/dental insurance costs are $ ___.

2. Amount.
Child support established at the rate of $_________per month for the _______children {total
number of parties’ minor or dependent children} shall be paid commencing ____________________
{month, day, year} and terminating ________________________________ {month, day, year}. Child
support shall be paid in the amount of $________ per _______________ {week, month, other}
consistent with the Obligor’s current payroll cycle.
Upon the termination of the obligation of child support for one of the parties’ children, child support
in the amount of $__________for the remaining _______children {total number of remaining
children} shall be paid commencing _______________________________ {month, day, year} and
terminating_____________________________ {month, day, year}. This child support shall be paid
in the amount of $________per __________ {week, month, other} consistent with the Obligor’s
current payroll cycle.

Florida Supreme Court Approved Family Law Form 12.990(c)(1), Final Judgment of Dissolution of Marriage with
Dependent or Minor Child(ren) (03/15)
- 805 -
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

The Obligor shall pay child support until all of the minor or dependent children: reach the age of 18;
become emancipated, marry, join the armed services, die, or become self-supporting; or until
further order of the court or agreement of the parties. The child support obligation shall continue
beyond the age of 18 and until high school graduation for any child who is dependent in fact,
between the ages of 18 and 19, and is still in high school, performing in good faith with a reasonable
expectation of graduation before the age of 19.

3. Arrearage/Retroactive Child Support.
a. ____There is no child support arrearage at the time of this Final Judgment.

b. ____The ____ Wife ____ Husband shall pay to the other spouse the child support arrearage of:
$ for retroactive child support, as of {date} ______________;
$ for previously ordered unpaid child support, as of {date} ______.
The total of $ ___ in child support arrearage shall be repaid in the amount of
$ _ per month, payable _____ in accordance with Obligor’s employer’s payroll cycle,
and in any event at least a month _____ other {explain} _______________________________
______________________________________________________________________________
beginning {date}_________________________, until paid in full including statutory interest.

4. Insurance.

a. _____Health/Dental Insurance. _____ Wife _____ Husband shall be required to maintain
_____health and/or _____ dental insurance for the parties’ minor child(ren), so long as
reasonable in cost and accessible to the child(ren). The party providing insurance shall be
required to convey insurance cards demonstrating said coverage to the other party;
OR
_____ health and/or _____ dental insurance is not reasonable in cost or accessible to the
child(ren) at this time.

Florida Supreme Court Approved Family Law Form 12.990(c)(1), Final Judgment of Dissolution of Marriage with
Dependent or Minor Child(ren) (03/15)
- 806 -
b. _____Reasonable and necessary uninsured medical/dental/prescription drug costs for the
minor child(ren) shall be assessed as follows:
_____ Shared equally by husband and wife.
_____ Prorated according to the child support guideline percentages.
_____ Other {explain}:
______________________________________________________________________________
______________________________________________________________________________
As to these uninsured medical/dental/prescription drug expenses, the party who incurs the
expense shall submit request for reimbursement to the other party within 30 days, and the
other party, within 30 days of receipt, shall submit the applicable reimbursement for that
expense, according to the schedule of reimbursement set out in this paragraph.

5. ______Life Insurance (to secure payment of support). To secure the child support obligations in
this judgment, _____ Husband _____Wife _____ Each party shall maintain life insurance, in an
amount of at least $______________, on _____ his life _____ her life _____ naming minor
child(ren) as the beneficiary(ies) OR naming the _____ Wife _____Husband _____other
{name}________________________________________________________________as Trustee for
the minor child(ren), so long as reasonably available. The obligation to maintain the life insurance
shall continue until the youngest child turns 18, becomes emancipated, marries, joins the armed
services, dies, or becomes self-supporting.

6. IRS Income Tax Exemption(s). The assignment of any tax exemption(s) for the child(ren) shall be as
follows: __________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________.
Each party shall execute any and all IRS forms necessary to effectuate the provisions of this
paragraph.

7. Other provisions relating to child support: ______________________________________________
__________________________________________________________________________________
_________________________________________________________________________________.

SECTION VI. METHOD OF PAYMENT
Obligor shall pay court-ordered child support/alimony and arrears, if any, as follows:

3. Place of Payment.

c. _____Obligor shall pay court-ordered support directly to either the State Disbursement
Unit or the central depository, as required by statute, along with any fee required by
statute.

d. _____Both parties have requested and the court finds that it is in the best interests of

Florida Supreme Court Approved Family Law Form 12.990(c)(1), Final Judgment of Dissolution of Marriage with
Dependent or Minor Child(ren) (03/15)
- 807 -
the child(ren) that support payments need not be directed through either the State
Disbursement Unit or the central depository at this time; however, either party may
subsequently apply, pursuant to section 61.13(1)(d)3, Florida Statutes, to require
payment through either the State Disbursement Unit or the central depository.

4. Income Deduction.

c. _____Immediate. Obligor shall pay through income deduction, pursuant to a separate Income
Deduction Order which shall be effective immediately. Obligor is individually responsible for
paying this support obligation until all of said support is deducted from Obligor’s income. Until
support payments are deducted from Obligor’s paycheck, Obligor is responsible for making
timely payments directly to the State Disbursement Unit or the Obligee, as previously set forth
in this order.
d. ______Deferred. Income deduction is ordered this day, but it shall not be effective until a
delinquency of $__________, or, if not specified, an amount equal to one month’s obligation
occurs. Income deduction is not being implemented immediately based on the following
findings: Income deduction is not in the best interests of the child(ren) because: {explain}
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________,
AND
There is proof of timely payment of a previously ordered obligation without an Income
Deduction Order in cases of modification,
AND
_____There is an agreement by the Obligor to advise the Title IV-D agency, the clerk of court,
and the Obligee of any change in Payor and/or health insurance OR
_____there is a signed written agreement providing an alternative arrangement between the
Obligor and the Obligee and, at the option of the IV-D agency, by the IV-D agency in IV-D cases
in which there is an assignment of support rights to the state, reviewed and entered in the
record by the court.

5. Bonus/one-time payments. _____ All ________% _____ No income paid in the form of a bonus or
other similar one-time payment, up to the amount of any arrearage or the remaining balance
thereof owed pursuant to this order, shall be forwarded to Obligee pursuant to the payment
method prescribed above.

6. Other provisions relating to method of payment. _________________________________________
__________________________________________________________________________________
_________________________________________________________________________________.

SECTION VII. ATTORNEY’S FEES, COSTS, AND SUIT MONEY
1. _____ Husband’s _____Wife’s request(s) for attorney’s fees, costs, and suit money is (are) denied

Florida Supreme Court Approved Family Law Form 12.990(c)(1), Final Judgment of Dissolution of Marriage with
Dependent or Minor Child(ren) (03/15)
- 808 -
because: _________________________________________________________________________
________________________________________________________________________________.

2. _____The Court finds there is a need for and an ability to pay attorney’s fees, costs, and suit money.
_____ Husband _____ Wife is hereby ordered to pay to the other spouse $______________
in attorney’s fees, and $ __________ in costs. The Court further finds that the attorney’s fees
awarded are based on the reasonable rate of $ __________ per hour and _________ reasonable
hours. Other provisions relating to attorney’s fees, costs, and suit money are as follows:
__________________________________________________________________________________
_________________________________________________________________________________.

SECTION VIII. OTHER PROVISIONS
1. Former Name. The wife’s former name of {full name} ______________________________________
is restored.

2. Other Provisions.
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________.

3. The Court reserves jurisdiction to modify and enforce this Final Judgment.

DONE AND ORDERED at ______, Florida, on ____________________________.

_______________________________________
CIRCUIT JUDGE

Florida Supreme Court Approved Family Law Form 12.990(c)(1), Final Judgment of Dissolution of Marriage with
Dependent or Minor Child(ren) (03/15)
- 809 -
I certify that a copy of this Final Judgment of Dissolution was ( ) mailed ( ) faxed and mailed ( ) e-
mailed ( ) hand delivered to the parties listed below on {date} ___________________.

_________________________________
By {clerk of court or designee}

____Husband (or his attorney)
____Wife Respondent (or her attorney)
____Central Depository
____State Disbursement Unit
____Other __________________________________

Florida Supreme Court Approved Family Law Form 12.990(c)(1), Final Judgment of Dissolution of Marriage with
Dependent or Minor Child(ren) (03/15)
- 810 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA

Case No.:
Division:
In re the Marriage of:

_____________________________
Husband,

and

______________________________,
Wife.

FINAL JUDGMENT OF DISSOLUTION OF MARRIAGE WITH
PROPERTY BUT NO DEPENDENT OR MINOR CHILD(REN)
This cause came before this Court for a trial on a Petition for Dissolution of Marriage. The Court, having
reviewed the file and heard the testimony, makes these findings of fact and reaches these conclusions of
law:
1. The Court has jurisdiction over the subject matter and the parties.
2. At least one party has been a resident of the State of Florida for more than 6 months
immediately before filing the Petition for Dissolution of Marriage.
3. The parties have no minor children in common, and the wife is not pregnant.
4. The marriage between the parties is irretrievably broken. Therefore, the marriage between the
parties is dissolved and the parties are restored to the status of being single.

SECTION I. MARITAL ASSETS AND LIABILITIES
A. Date of Valuation of Property. The assets and liabilities listed below are divided as
indicated. The date of valuation of these assets and liabilities is, unless otherwise indicated:
1._____ date of filing petition for dissolution of marriage .
2._____ date of separation .
3. _____ date of final hearing .
4. _____ other: {specify date}____________________________________________.

B. Division of Assets.
1. The assets listed below are nonmarital assets. Each party shall keep, as his or her own, the
assets found to be nonmarital, and the other party shall have no further rights or responsibilities
regarding these assets.

Florida Supreme Court Approved Family Law Form 12.990(c)(2), Final Judgment of Dissolution of Marriage with
Property but No Dependent or Minor Child(ren) (03/15)
- 811 -
Current Wife’s Husband’s
ASSETS: DESCRIPTION OF ITEM(S) Fair Non Non
Please describe each item as clearly as possible. Market marital marital
You do not need to list account numbers. Value Property Property
$ $ $

Total Nonmarital Assets $ $ $

2. The assets listed below are marital assets. Each party shall keep, as his or her own, the assets
awarded in this section, and the other party shall have no further rights or responsibilities
regarding these assets. Any personal item(s) not listed below are awarded to the party
currently in possession or control of the item(s).

Current Husband
ASSETS: DESCRIPTION OF ITEM(S) Fair Wife Shall
Please describe each item as clearly as possible. Market Shall Receive
You do not need to list account numbers. Value Receive
Cash (on hand or in banks/credit unions) $ $ $

Stocks/bonds

Notes
Business interests

Real estate: (Home)

Automobiles

Florida Supreme Court Approved Family Law Form 12.990(c)(2), Final Judgment of Dissolution of Marriage with
Property but No Dependent or Minor Child(ren) (03/15)
- 812 -
Boats
Furniture & furnishings

Jewelry

Life insurance (cash surrender value)
Retirement Plans (Profit sharing, Pension, IRA, 401(k)s, etc.)

Other assets

Total Marital Assets $ $ $

Florida Supreme Court Approved Family Law Form 12.990(c)(2), Final Judgment of Dissolution of Marriage with
Property but No Dependent or Minor Child(ren) (03/15)
- 813 -
Wife’s Husband’s
LIABILITIES: DESCRIPTION OF DEBT(S) Current Non- Non-
Please describe each item as clearly as possible. Amount marital marital
You do not need to list account numbers) Owed Liability Liability
$ $ $

Total Nonmarital Liabilities $ $ $

2. The liabilities listed below are marital liabilities and are divided as indicated. Each party shall
hold the other party harmless and pay, as his or her own, the marital liabilities awarded below.

LIABILITIES: DESCRIPTION OF DEBT(S) Current
Please describe each item as clearly as possible. Amount Wife Husband
You do not need to list account numbers. Owed Shall Pay Shall Pay
Mortgages on real estate: (Home) $ $ $
(Other)

Charge/credit card accounts

Auto loan
Auto loan
Bank/Credit Union loans

Other

Florida Supreme Court Approved Family Law Form 12.990(c)(2), Final Judgment of Dissolution of Marriage with
Property but No Dependent or Minor Child(ren) (03/15)
- 814 -
Total Marital Liabilities $ $ $

D. Contingent assets and liabilities will be divided as follows:________________________________
__________________________________________________________________________________

F. Beneficiary Designation (By completing this section, the beneficiary designations continue after
Entry of Final Judgment of Dissolution of Marriage.)

The designation providing for the payment or transfer at death of an interest in the assets described
below to or for the benefit of the deceased party’s former spouse is NOT VOID as of the date of
entry of the Final Judgment of Dissolution of Marriage.

The Final Judgment of Dissolution of Marriage shall provide that the designations set forth below
remain in full force and effect.

_____ 1. The _____ Husband _____Wife shall acquire or maintain the following assets for the
benefit of the other spouse or child(ren) to be paid upon his/her death outright or in trust. This
provision only applies if other assets fulfilling such requirement for the benefit of the other spouse
or child(ren) do not exist upon his/her death and unless precluded by statute. {Describe the assets
with specificity}
_________________________________________________________________________________
_________________________________________________________________________________
________________________________________________________________________________.

_____2. The _____ Husband _____ Wife shall not unilaterally terminate or modify the ownership of

Florida Supreme Court Approved Family Law Form 12.990(c)(2), Final Judgment of Dissolution of Marriage with
Property but No Dependent or Minor Child(ren) (03/15)
- 815 -
the following assets, or their disposition upon his/her death. {Describe the assets with specificity}
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________.

SECTION II. EXCLUSIVE USE AND POSSESSION OF HOME
{Indicate all that apply}
1. _____ The _____ Husband _____ Wife, as a condition of support, shall have exclusive use and
possession of the dwelling located at the following address:
__________________________________________________________________________
until {date or event}____________________________________________________________
______________________________________________________________________________.

2. _____The_____ Husband ______Wife may make visits to the premises described in the
paragraph above for the purpose of obtaining any items awarded in this Final Judgment.
These visits shall occur after notice to the person granted exclusive use and possession of the
dwelling and at the earliest convenience of both parties or as ordered in paragraph 4 below.

3. _____Upon the termination of the right of exclusive use and possession, the dwelling shall be
sold and the net proceeds divided % to Husband and % to Wife, with the
following credits and/or setoffs being allowed:_______________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.

4. _____Other: ____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.

SECTION III. ALIMONY
1. _____ The Court denies the request(s) for alimony
OR
2. _____ The Court finds that there is an actual need for, and that _____ Husband _____ Wife
(hereinafter Obligor) has/had the present ability to pay, alimony as follows:
{Indicate all that apply}
a. _____ Permanent Periodic.
1. The Court finds that no other form of alimony is fair and reasonable under the

Florida Supreme Court Approved Family Law Form 12.990(c)(2), Final Judgment of Dissolution of Marriage with
Property but No Dependent or Minor Child(ren) (03/15)
- 816 -
circumstances of the parties.

2. As a marriage of: {Choose only one}

_____Long Duration (17 years or greater) alimony is appropriate upon
consideration of all relevant factors;

_____Moderate Duration (greater than 7 years but less than 17) alimony is
appropriate based upon clear and convincing evidence after
consideration of all relevant factors; or

_____Short Duration (less than 7 years) alimony is appropriate based upon
the following exceptional circumstances:_____________
___________________________________________________________
__________________________________________________________.

3. Obligor shall pay permanent periodic alimony to Obligee in the amount of
$ per month, payable ____ in accordance with Obligor’s
employer’s payroll cycle, and in any event, at least once a month or ____
other {explain}:___________________________________________________
__________________________________________________________
beginning {date} ___________. This alimony shall continue until
modified by court order, the death of either party, or remarriage of Obligee,
whichever occurs first. The alimony may be modified or terminated based
upon either a substantial change in circumstances or the existence of a
supportive relationship in accordance with section 61.14, Florida Statutes.

b._____Bridge-the-Gap. Obligor shall pay bridge-the-gap alimony to Obligee in the amount of
$_________ per month, payable _____ in accordance with Obligor’s employer’s payroll
cycle, and in any event, at least once a month or _____ other {explain} _________________
beginning {date}__________________and continuing until {date}______________________
{a period not to exceed two years}, the death of either party, or remarriage of the Obligee,
whichever occurs first.

c.______Rehabilitative. Obligor shall pay rehabilitative alimony to Obligee in the amount of
$ ______ per month, payable _____ in accordance with Obligor’s employer’s payroll
cycle, and in any event, at least once a month or _____other {explain}________
beginning {date} ______________. This rehabilitative alimony shall continue until modified
by court order, the death of either party or until {date/event} _______________________ ,
whichever occurs first. The rehabilitative plan presented demonstrated the following:
___________________________________________________________________________
___________________________________________________________________________.

Florida Supreme Court Approved Family Law Form 12.990(c)(2), Final Judgment of Dissolution of Marriage with
Property but No Dependent or Minor Child(ren) (03/15)
- 817 -
d._____Durational. Obligor shall pay durational alimony to Obligee in the amount of
$_________ per month ____ payable in accordance with Obligor’s employer’s payroll cycle,
and in any event, at least once a month or ____ {explain}_____________________________
beginning {date}____________ and terminating on {date}______________________, the
death of either party, remarriage of Obligee, or until modified by court order in accordance
with section 61.08(7), Florida Statutes, whichever occurs first.

e._____ Lump Sum. Obligor shall pay lump sum alimony to Obligee in the amount of
$_____________, which shall be paid as follows:______________________________
____________________________________________________________________ .

f._____Retroactive. Obligor shall pay retroactive alimony in the amount of $ ____________
for the period of {date}___________________, through {date} ,
which shall be paid pursuant to paragraph 4 below.

3. Reasons for _____ Awarding _____ Denying Alimony. The Court has considered all of the
following in awarding/denying alimony:
a. The standard of living established during the marriage;
b. The duration of the marriage;
c. The age and the physical and emotional condition of each party;
d. The financial resources of each party, including, the nonmarital and the marital assets and
liabilities distributed to each;
e. The earning capacities, educational levels, vocational skills, and employability of the parties
and, when applicable, the time necessary for either party to acquire sufficient education or
training to enable such party to find appropriate employment;
f. The contribution of each party to the marriage, including, but not limited to, services
rendered in homemaking, child care, education, and career building of the other party;
g. The tax treatment and consequences to both parties of any alimony award, including the
designation of all or a portion of the payment as a nontaxable, nondeductible payment;
h. All sources of income available to either party, including income available to either party
through investments of any asset held by the party; and
i. Any other factor necessary to do equity and justice between the parties: {explain}________

______ Please indicate here if additional pages are attached.

4. Arrearage/Retroactive Alimony.

a. ____ There is no alimony arrearage at the time of this Final Judgment.
OR

Florida Supreme Court Approved Family Law Form 12.990(c)(2), Final Judgment of Dissolution of Marriage with
Property but No Dependent or Minor Child(ren) (03/15)
- 818 -
b.____ The ____ Husband ____ Wife shall pay to the other party the alimony arrearage of:
$ for retroactive alimony, as of {date} ;
$ for previously ordered unpaid alimony, as of {date} _____.
The total of $ in alimony arrearage shall be repaid in the amount of $ per
month, payable ( ) in accordance with Obligor’s employer’s payroll cycle, and in any event at
least once a month ( ) other {explain}______________________________________________
_____________________________________________________________________________
beginning {date} , until paid in full including statutory interest.

5. _____Life Insurance (to secure payment of support). To secure the alimony obligations set
forth in this judgment, Obligor shall maintain life insurance coverage on his/her life naming
Obligee as the sole irrevocable beneficiary, so long as reasonably available. This insurance shall
be in the amount of at least $ ________ and shall remain in effect until the obligation for
alimony terminates.

6. _____Other provisions relating to alimony, including any tax treatment and consequences:

a. The award of alimony _____does not _____does leave the Obligor with significantly less net
income than the net income of the recipient/Obligee. If yes, the court finds the following
exceptional circumstances:_____________________________
_______________________________________________________________________
_______________________________________________________________________ .
b. Other:_______________________________________________________________________
___________________________________________________________________________.

SECTION IV. METHOD OF PAYMENT
Obligor shall pay court-ordered alimony and arrears, if any, as follows:

1. Place of Payment.

a. _____ Obligor shall pay court-ordered support directly to either the State Disbursement Unit
or the central depository, as required by statute, along with any fee required by statute.

b. _____ Both parties have requested and the court finds that support payments need not be
directed through either the State Disbursement Unit or the central depository at this time at
this time; however, either party may subsequently apply, pursuant to section 61.13(1)(d)3,
Florida Statutes, to require payments through either the State Disbursement Unit or the
central depository.

2. Income Deduction.

a. _____ Immediate. Obligor shall pay through income deduction, pursuant to a separate

Florida Supreme Court Approved Family Law Form 12.990(c)(2), Final Judgment of Dissolution of Marriage with
Property but No Dependent or Minor Child(ren) (03/15)
- 819 -
Income Deduction Order which shall be effective immediately. Obligor is individually
responsible for paying this support obligation until all of said support is deducted from
Obligor’s income. Until support payments are deducted from Obligor’s paycheck, Obligor is
responsible for making timely payments directly to the State Disbursement Unit or the
Obligee, as previously set forth in this order.

b. _____ Deferred. Income Deduction is ordered this day, but it shall not be effective until a
delinquency of $ , or, if not specified, an amount equal to one month’s obligation
occurs. Income deduction is not being implemented immediately based on the following
findings:
There are no minor or dependent child(ren) common to the parties,
AND
There is proof of timely payment of a previously ordered obligation without an Income
Deduction Order in cases of modification,
AND
_____ There is an agreement by the Obligor to advise the Title IV-D agency, the clerk of
court, and the Obligee of any change in Payor and/or health insurance OR _____ there is a
signed written agreement providing an alternative arrangement between the Obligor and
the Obligee and, at the option of the IV-D agency, by the IV-D agency in IV-D cases in which
there is an assignment of support rights to the state, reviewed and entered in the record by
the court.

3. Bonus/one-time payments. _____ All _____% _____ No income paid in the form of a bonus or
other similar one-time payment, up to the amount of any arrearage or the remaining balance
thereof owed pursuant to this order, shall be forwarded to Obligee pursuant to the payment
method prescribed above.

4. Other provisions relating to method of payment. _____________________________________

SECTION V. ATTORNEY’S FEES, COSTS, AND SUIT MONEY
1. ____ Husband’s ____ Wife’s request(s) for attorney’s fees, costs, and suit money is
(are) denied because
________________________________________________________________
.

Florida Supreme Court Approved Family Law Form 12.990(c)(2), Final Judgment of Dissolution of Marriage with
Property but No Dependent or Minor Child(ren) (03/15)
- 820 -
the attorney’s fees awarded are based on the reasonable rate of $ per hour
and ______ reasonable hours. Other provisions relating to attorney’s fees, costs, and
suit money are as follows:
_______________________________________________________________________
.

SECTION VI. OTHER PROVISIONS
1. Former Name. The wife’s former name of {full name} ___________________________is
restored.

2. Other Provisions.

3. The Court reserves jurisdiction to modify and enforce this Final Judgment.

DONE AND ORDERED on ___________ in __________________________, Florida.

CIRCUIT JUDGE

I certify that a copy of this Final Judgment of Dissolution was ( ) mailed ( ) faxed and mailed
( ) e-mailed ( ) hand-delivered to the parties or entities listed below on {date} _________________.

___________________________________
By: {Clerk of court or designee}

_____Husband (or his attorney)
_____Wife (or her attorney)
_____Central depository
_____State Disbursement Unit
_____Other:

Florida Supreme Court Approved Family Law Form 12.990(c)(2), Final Judgment of Dissolution of Marriage with
Property but No Dependent or Minor Child(ren) (03/15)
- 821 -
IN THE CIRCUIT COURT OF THE ________________________JUDICIAL CIRCUIT,
IN AND FOR COUNTY, _______________________FLORIDA

Case No.:
Division:
_________________________________,
Petitioner,

and

_________________________________,
Respondent.

SUPPLEMENTAL FINAL JUDGMENT MODIFYING PARENTAL
RESPONSIBILITY, VISITATION, OR PARENTING
PLAN/TIME-SHARING SCHEDULE AND OTHER RELIEF
This cause came before this Court on a Supplemental Petition to Modify Parental Responsibility,
Visitation, or Parenting Plan/Time-Sharing Schedule and Other Relief. The Court, having reviewed the
file, having heard the testimony, and being otherwise fully advised, makes these findings of fact and
reaches these conclusions of law:

SECTION I. FINDINGS

1. The Court has jurisdiction over the subject matter and the parties.

2. The last order establishing or modifying parental responsibility, visitation, a Parenting Plan, or time-
sharing was entered on {date} ________________________.

3. There has been a substantial change in circumstances of the parties since the entry of the last order,
specifically: ________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________.

4. It is in the best interests of the minor child(ren) that the current parental responsibility, visitation,
time-sharing schedule or Parenting Plan be changed because:________________________________
__________________________________________________________________________________

Florida Supreme Court Approved Family Law Form 12.993(a), Supplemental Final Judgment Modifying Parental
Responsibility, Visitation, or Parenting Plan/Time-Sharing Schedule and Other Relief (03/15)
- 822 -
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________.
SECTION II. PARENTING PLAN ESTABLISHING PARENTAL RESPONSIBILITY AND TIME-SHARING WITH
DEPENDENT OR MINOR CHILD(REN)

1. Jurisdiction. The Court has jurisdiction to determine parental responsibility, to establish or approve
a Parenting Plan, and time-sharing with regard to the parties’ minor child(ren) listed in paragraph 2
below.

2. The parties’ dependent or minor child(ren) is (are):
Name Birth date
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

3. Parenting Plan. The parties shall comply with the Parenting Plan which is attached and
incorporated herein as Exhibit ______.

SECTION III. CHILD SUPPORT
1. Modification of Child Support.
{Choose one only}
a. ______The modification of parental responsibility or time-sharing entered above does not
necessitate a modification of child support. The previous order or final judgment establishing or
modifying child support shall remain in effect.

b. ______The Court finds that there is a need for modification of child support and that the
______ Mother ______ Father (hereinafter Obligor) has the present ability to pay child support.
The amounts in the Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure
Form 12.902(e), filed by the ______ Mother ______ Father are correct OR the Court makes the
following findings:

The Mother’s net monthly income is $____________, (Child Support Guidelines _____%).
The Father’s net monthly income is $_____________, (Child Support Guidelines _____%).
Monthly child care costs are $_______________.
Monthly health/dental insurance costs are $___________.

2. Amount.

Florida Supreme Court Approved Family Law Form 12.993(a), Supplemental Final Judgment Modifying Parental
Responsibility, Visitation, or Parenting Plan/Time-Sharing Schedule and Other Relief (03/15)
- 823 -
Child support established at the rate of $_____________ per month for the _______children {total
number of parties’ minor or dependent children} shall be paid commencing ____________________
{month, day, year} and terminating _________________________________ {month, day, year}.
Child support shall be paid in the amount of $___________per ____________ {week, month, other}
which is consistent with the Obligor’s current payroll cycle.

Upon the termination of the obligation of child support for one of the parties’ children, child support
in the amount of $_____________for the remaining _______ children {total number of remaining
children} shall be paid commencing___________________________________ {month, day, year}
and terminating_________________________________ {month, day, year}. This child support shall
be paid in the amount of $____________ per ____________ {week, month, other} consistent with
the Obligor’s current payroll cycle.

{Insert schedule for the child support obligation, including the amount, and commencement and
termination dates, for the remaining minor or dependent children, which shall be payable as the
obligation for each child ceases. Please indicate whether the schedule ______appears below or
_____ is attached as part of this form.}
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.

The Obligor shall pay child support until all of the minor or dependent child(ren): reach the age of
18; become emancipated, marry, join the armed services, die, or become self-supporting; or until
further order of the court or agreement of the parties. The child support obligation shall continue
beyond the age of 18 and until high school graduation for any child who is dependent in fact,
between the ages of 18 and 19, and is still in high school, performing in good faith with a reasonable
expectation of graduation before the age of 19.

3. Arrearage/Retroactive Child Support.
{Choose one only}

a. _____There is no child support arrearage at the time of this Supplemental Final Judgment.
OR
b. _____The _____ Mother _____ Father shall pay to the other party the child support arrearage of:

Florida Supreme Court Approved Family Law Form 12.993(a), Supplemental Final Judgment Modifying Parental
Responsibility, Visitation, or Parenting Plan/Time-Sharing Schedule and Other Relief (03/15)
- 824 -
$_____________ for retroactive child support, as of {date}_________________________________.
$_____________ for previously ordered unpaid child support, as of {date}_____________________.
The total of $________________ in child support arrearage shall be repaid in the amount of
$________________, per month payable ______ in accordance with Obligor’s employer’s payroll
cycle, and in any event at least once a month _____ other {explain} ___________________beginning
{date} _____________________________ until paid in full including statutory interest.

4. Insurance.
[Indicate all that apply]
a. ______Health/Dental Insurance. _____ Mother _____ Father shall be required to maintain
_____health and/or _____ dental insurance for the parties’ minor child(ren), so long as
reasonable in cost and accessible to the child(ren) . The party providing insurance shall be
required to convey insurance cards demonstrating said coverage to the other party;
OR
______ health and/or ______ dental insurance is not reasonable in cost or accessible to the
child(ren) at this time.

b. _____Reasonable and necessary uninsured medical/dental/prescription drug costs for the
minor child(ren) shall be assessed as follows:
_____ Shared equally by both parents.
_____ Prorated according to the child support guideline percentages.
_____ Other {explain}: ___________________________________________________________
___________________________________________________________________________
As to these uninsured medical/dental/prescription drug expenses, the party who incurs the
expense shall submit a request for reimbursement to the other party within 30 days, and the
other party, within 30 days of receipt, shall submit the applicable reimbursement for that
expense, according to the schedule of reimbursement set out in this paragraph.

5. ______Life Insurance (to secure payment of support). To secure the child support obligations in this
judgment, ______ Mother ______ Father ______Each parent shall maintain life insurance, in an
amount of at least $ ________, on ______ his life ______ her life ______ his/her life naming
the _____ minor child(ren) as the beneficiary(ies) OR naming the _____ Mother _____ Father
_____ other {name}_____________________________________as Trustee for the minor child(ren),
so long as reasonably available. The obligation to maintain the life insurance shall continue until the
youngest child turns 18, becomes emancipated, marries, joins the armed services, dies, or becomes
self-supporting.

6. ______IRS Income Tax Exemption(s). The assignment of any tax exemption(s) for the child(ren) shall
be as follows: ______________________________________________________________________
_________________________________________________________________________________.

Florida Supreme Court Approved Family Law Form 12.993(a), Supplemental Final Judgment Modifying Parental
Responsibility, Visitation, or Parenting Plan/Time-Sharing Schedule and Other Relief (03/15)
- 825 -
Further, each party shall execute any and all IRS forms necessary to effectuate the provisions of this
paragraph.

SECTION IV. METHOD OF PAYMENT

Obligor shall pay court-ordered child support and arrears, if any, as follows:

1. Place of Payment.

a. _____Obligor shall pay court-ordered support directly to either the State Disbursement
Unit or the central depository, as required by statute, along with any fee required by
statute.

b. _____Both parties have requested and the court finds that it is in the best interests of
the child(ren) that support payments need not be directed through either the State
Disbursement Unit or the central depository at this time; however, either party may
subsequently apply, pursuant to section 61.13(1)(d)3, Florida Statutes, to require
payments through either the State Disbursement Unit or the central depository.

2. Income Deduction.

a. ______Immediate. Obligor shall pay through income deduction, pursuant to a separate Income
Deduction Order which shall be effective immediately. Obligor is individually responsible for
paying this support obligation until all of said support is deducted from Obligor’s income. Until
support payments are deducted from Obligor’s paycheck, Obligor is responsible for making
timely payments directly to the State Disbursement Unit or the Obligee, as previously set forth
in this order.

b. ______Deferred. Income deduction is ordered this day, but it shall not be effective until a
delinquency of $____________, or, if not specified, an amount equal to one month’s obligation
occurs. Income deduction is not being implemented immediately based on the following
findings: Income deduction is not in the best interests of the child(ren) because: {explain}
______________________________________________________________________________
______________________________________________________________________________,

AND
There is proof of timely payment of a previously ordered obligation without an income

Florida Supreme Court Approved Family Law Form 12.993(a), Supplemental Final Judgment Modifying Parental
Responsibility, Visitation, or Parenting Plan/Time-Sharing Schedule and Other Relief (03/15)
- 826 -
deduction order,
AND
_____ There is an agreement by the Obligor to advise the Title IV-D agency, the clerk of court,
and the Obligee of any change in Payor and/or health insurance OR
_____ there is a signed written agreement providing an alternative arrangement between
the Obligor and the Obligee and, at the option of the IV-D agency, by the IV-D agency in IV-D
cases in which there is an assignment of support rights to the state, reviewed and entered in the
record by the court.

3. Bonus/one-time payments. _____All _________% _____No income paid in the form of a bonus or
other similar one-time payment, up to the amount of any arrearage or the remaining balance
thereof owed pursuant to this order, shall be forwarded to the Obligee pursuant to the payment
method prescribed above.

4. Other provisions relating to method of payment. ________________________________________
__________________________________________________________________________________
_________________________________________________________________________________.

SECTION V. ATTORNEY’S FEES, COSTS, AND SUIT MONEY

1. _____ Mother’s _____ Father’s request(s) for attorney’s fees, costs, and suit money is (are) denied
because __________________________________________________________________________
_________________________________________________________________________________.

2. _____The Court finds there is a need for and an ability to pay attorney’s fees, costs, and suit money.
_____ Mother _____ Father is hereby ordered to pay to the other party $____________ in
attorney’s fees, and $____________ in costs. The Court further finds that the attorney’s fees
awarded are based on the reasonable rate of $____________ per hour and ____________
reasonable hours. Other provisions relating to attorney’s fees, costs, and suit money are as follows:
_________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________.

SECTION VI. OTHER

1. Other Provisions. ___________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________.

2. The Court reserves jurisdiction to modify and enforce this Supplemental Final Judgment.

Florida Supreme Court Approved Family Law Form 12.993(a), Supplemental Final Judgment Modifying Parental
Responsibility, Visitation, or Parenting Plan/Time-Sharing Schedule and Other Relief (03/15)
- 827 -
3. Unless specifically modified by this Supplemental Final Judgment, the provisions of all final
judgments or orders in effect remain the same.

DONE AND ORDERED at __________________________, Florida, on _____________________.

_____________________________________________
CIRCUIT JUDGE

I certify that a copy of the {name of document(s)} __________________________________________
was: ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the parties and any
entities listed below on {date}____________________________.

by____________________________________
{Clerk of court or designee}

_____Petitioner (or his or her attorney)
_____Respondent (or his or her attorney)
_____Central Depository
_____State Disbursement Unit
Other:________________________

Case No.:
Division:
,
Petitioner,

and

,
Respondent.

SUPPLEMENTAL FINAL JUDGMENT MODIFYING CHILD SUPPORT
This cause came before this Court on a Supplemental Petition for Modification of Child Support. The
Court, having heard the testimony and reviewed the file and financial affidavits of the parties and being
otherwise fully advised, makes these findings of fact and reaches these conclusions of law:

SECTION I. FINDINGS

1. The Court has jurisdiction over the subject matter and the parties.

2. The parties’ dependent or minor child(ren) is (are):
Name Birth date

3. The last order awarding or modifying child support was entered on {date} __________________

4. There has been a substantial change in circumstances of the parties since the entry of the last
order, specifically: _______________________________________________________________

5. It is in the best interests of the minor child(ren) that the current child support order be changed

Florida Supreme Court Approved Family Law Form 12.993(b), Supplemental Final Judgment Modifying Child
Support (03/15)
- 829 -
because:
______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________.

SECTION II. CHILD SUPPORT

1. The Court finds that there is a need for modification of child support and that the _____ Mother
_____ Father (hereinafter Obligor) has the present ability to pay child support. The amounts in
the Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e),
filed by the _____ Mother _____ Father are correct OR the Court makes the following findings:

The Mother’s net monthly income is $ __, (Child Support Guidelines _ ___%).
The Father’s net monthly income is $ ____, (Child Support Guidelines _____%).
Monthly child care costs are $ ________.
Monthly health/dental insurance costs are $ .

2. Amount.
Child support established at the rate of $__________ per month for the _______children {total
number of parties’ minor or dependent children} shall be paid commencing________________
{month, day, year} and terminating_____________________________ {month, day, year}. Child
support shall be paid in the amount of $______________ per ______________ {week, month,
other} consistent with the Obligor’s current payroll cycle.
Upon the termination of the obligation of child support for one of the parties’ children, child
support in the amount of $_____________for the remaining ______ children {total number of
remaining children} shall be paid commencing__________________ {month, day, year} and
terminating ______________________ month, day, year}. This child support shall be paid in the
amount of $____________ per ____________ {week, month, other} consistent with the
Obligor’s current payroll cycle.

Florida Supreme Court Approved Family Law Form 12.993(b), Supplemental Final Judgment Modifying Child
Support (03/15)
- 830 -
________________________________________________________________________
________________________________________________________________________
_________________________________________________________________________.
The Obligor shall pay child support until all of the minor or dependent children: reach the age of
18; become emancipated, marry, join the armed services, die, or become self-supporting; or
until further order of the court or agreement of the parties. The child support obligation shall
continue beyond the age of 18 and until high school graduation for any child who is dependent
in fact, between the ages of 18 and 19, and is still in high school, performing in good faith with a
reasonable expectation of graduation before the age of 19.
If the child support ordered deviates from the guidelines by more than 5%, the factual findings
which support that deviation are:

3. Arrearage/Retroactive Child Support.

a. ____There is no child support arrearage at the time of this Supplemental Final Judgment.
OR
b. _____ Mother _____ Father shall pay to the other party the child support arrearage of:
$ __ for retroactive child support, as of {date} ___________.
$ __ for previously ordered unpaid child support, as of {date} ___________________.
The total of $ _ in child support arrearage shall be repaid in the amount of $ ______,
per month payable _____ in accordance with his or her employer’s payroll cycle, and in any
event at least once a month _____ other {explain} ____________________________________
beginning {date} ________, until paid in full including statutory interest.

4. Insurance.
{Indicate all that apply}

a. ______Health/Dental Insurance. _____ Mother _____ Father shall be required to maintain
______ health _____dental insurance for the parties’ minor child(ren), so long as it is
reasonable in cost and accessible to the child(ren). The party providing insurance shall be
required to convey insurance cards demonstrating said coverage to the other party OR
_____Health _____ Dental insurance is not reasonable in cost or accessible to the child(ren)
at this time.

b. _____Reasonable and necessary uninsured medical/dental/prescription costs for the minor
child(ren) shall be assessed as follows:
______ Shared equally by both parents.
______ Prorated according to the child support guideline percentages.

Florida Supreme Court Approved Family Law Form 12.993(b), Supplemental Final Judgment Modifying Child
Support (03/15)
- 831 -
______ Other {explain}: _______________________________________________________

As to these uninsured medical/dental/prescription expenses, the party who incurs the
expense shall submit a request for reimbursement to the other party within 30 days, and
the other party, within 30 days of receipt, shall submit the applicable reimbursement for
that expense, according to the schedule of reimbursement set out in this paragraph.

5. _____Life Insurance (to secure payment of support). To secure the child support obligations
in this judgment, _____ Mother _____ Father _____ Each party shall maintain life insurance
coverage, in an amount of at least $ __________, on _____ his life _____ her life
_____ his/her life naming the _____ minor child(ren) as the beneficiary(ies) OR naming the
_____Mother _____ Father _____ other {name}____________________________________
as Trustee for the minor child(ren), so long as reasonably available. The obligation to maintain
the life insurance coverage shall continue until the youngest child turns 18, becomes
emancipated, marries, joins the armed services, dies or otherwise becomes self-supporting.

7. Other provisions relating to child support: ________________________________________

___________________________________________________________________________.

SECTION III. METHOD OF PAYMENT

1. Place of Payment.

a. _____Obligor shall pay court-ordered support directly to either the State Disbursement Unit
or the central depository, as required by statute, along with any fee required by statute.

b. _____Both parties have requested and the court finds that it is in the best interests of the
child(ren) that support payments need not be directed through either the State
Disbursement Unit or the central depository at this time; however, either party may
subsequently apply, pursuant to section 61.13(1)(d)3, Florida Statutes, to require payments
through either the State Disbursement Unit or the central depository.

2. Income Deduction.

a. _____Immediate. Obligor shall pay through income deduction, pursuant to a separate
Income Deduction Order which shall be effective immediately. Obligor is individually

Florida Supreme Court Approved Family Law Form 12.993(b), Supplemental Final Judgment Modifying Child
Support (03/15)
- 832 -
responsible for paying this support obligation until all of said support is deducted from
Obligor’s income. Until support payments are deducted from Obligor’s paycheck, Obligor is
responsible for making timely payments directly to the State Disbursement Unit or the
Obligee, as previously set forth in this order.

b. _____Deferred. Income deduction is ordered this day, but it shall not be effective until a
delinquency of $ ____, or, if not specified, an amount equal to one month’s
obligation occurs. Income deduction is not being implemented immediately based on the
following findings:

Income deduction is not in the best interests of the child(ren) because: {explain} _____

,
AND
There is proof of timely payment of a previously ordered obligation without an Income
Deduction Order,
AND
_____ There is an agreement by the Obligor to advise the Title IV-D agency, the clerk of
court, and the Obligee of any change in Payor and/or health insurance
OR
_____ there is a signed written agreement providing an alternative arrangement between
the Obligor and the Obligee and, at the option of the IV-D agency, by the IV-D agency in IV-D
cases in which there is an assignment of support rights to the state, reviewed and entered in
the record by the court.

3. Bonus/one-time payments. _____ All ____% _____ No income paid in the form of a bonus or
other similar one-time payment, up to the amount of any arrearage or the remaining balance
thereof owed pursuant to this order, shall be forwarded to the Obligee pursuant to the payment
method prescribed above.

4. Other provisions relating to method of payment ______________________________________
.

SECTION IV. ATTORNEY’S FEES, COSTS, AND SUIT MONEY

1. _____ Mother’s _____ Father’s request(s) for attorney’s fees, costs, and suit money is
(are) denied because
________________________________________________________________
.

Florida Supreme Court Approved Family Law Form 12.993(b), Supplemental Final Judgment Modifying Child
Support (03/15)
- 833 -
that the attorney’s fees awarded are based on the reasonable rate of $ __ per
hour and _________reasonable hours. Other provisions relating to attorney’s fees,
costs, and suit money are as follows:

SECTION V. OTHER

1. Other Provisions.

2. The Court reserves jurisdiction to modify and enforce this Supplemental Final Judgment.

3. Unless specifically modified by this Supplemental Final Judgment, the provisions of all final
judgments or orders in effect remain the same.

DONE AND ORDERED at ____________________________, Florida, on .

CIRCUIT JUDGE

I certify that a copy of the {name of document(s)} ___________________________________________
was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the parties and any
entities listed below on {date}_____________________.

_____________________________________
By: {Clerk of court or designee}

______Petitioner (or his or her attorney)
______Respondent (or his or her attorney)
______Central Depository
______State Disbursement Unit

Florida Supreme Court Approved Family Law Form 12.993(b), Supplemental Final Judgment Modifying Child
Support (03/15)
- 834 -
______Other:_______________________

Florida Supreme Court Approved Family Law Form 12.993(b), Supplemental Final Judgment Modifying Child
Support (03/15)
- 835 -
IN THE CIRCUIT COURT OF THE _____________________JUDICIAL CIRCUIT,
IN AND FOR ________________________COUNTY, FLORIDA

Case No:_______________________
Division: ______________________

___________________________________,
Petitioner,
and
____________________________________,
Respondent.

SUPPLEMENTAL FINAL JUDGMENT MODIFYING ALIMONY
This cause came before this Court on a Supplemental Petition for Modification of Alimony. The Court,
having heard the testimony and reviewed the file and the financial affidavits of the parties and being
otherwise fully advised, makes these findings of fact and reaches these conclusions of law:

SECTION I. FINDINGS

1. The Court has jurisdiction over the subject matter and the parties.

2. The last order awarding or modifying alimony was entered on {date}______________________.

3. There has been a substantial change in circumstances of the parties since entry of the last order,
specifically: ____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.

SECTION II. ALIMONY

1. _____The Court denies the request(s) for modification of alimony
OR
2. _____ The Court finds that there is a need to modify alimony and that _____ Petitioner
_____ Respondent (hereinafter Obligor) has/had the present ability to pay alimony as follows:

{Indicate all that apply}
a. ______ Permanent Periodic. The permanent periodic alimony is _____ modified
_____ terminated based upon either _____ a substantial change in circumstances, OR _____ the
existence of a supportive relationship in accordance with Section 61.14, Florida Statutes.
Obligor shall pay modified permanent periodic alimony to Obligee in the amount of $_________
per month, payable _____ in accordance with Obligor’s employer’s payroll cycle, and in any
event, at least once a month, or _____ other : {explain} ________________________________
Florida Supreme Court Approved Family Law Form 12.993(c), Supplemental Final Judgment Modifying Alimony
(03/15)
- 836 -
_____________________________________________________________________________
beginning {date} _______________________. This alimony shall continue until further modified
by court order, the death of either party, or remarriage of Obligee, whichever occurs first

b. _____ Durational. The durational alimony is _____ modified _____terminated based upon a
substantial change in circumstances in accordance with section 61.08(7), Florida Statutes. If the
length of the durational alimony is modified, the court finds that the following exceptional
circumstances exist:__________________________________________________________
__________________________________________________________________________
Obligor shall pay modified durational alimony to Obligee in the amount of $_________
per month, payable _____ in accordance with Obligor’s employer’s payroll cycle, and in
any event, at least once a month _____ other {explain}___________________________
beginning {date} ___________________, and terminating on {date}_________________,
the death of either party, remarriage of the Obligee, or until further modified by court order,
whichever occurs first.

c. ______Rehabilitative. The rehabilitative alimony is _____ modified _____ terminated based
upon: _____ a substantial change in circumstances, _____ noncompliance with the rehabilitative
plan, or _____ completion of the rehabilitative plan. Obligor shall pay modified rehabilitative
alimony to Obligee in the amount of $__________ per month, payable _____ in accordance with
Obligor’s employer’s payroll cycle, and in any event, at least once a month, or _____ other
{explain} ___________________________ beginning {date} __________________________.
This modified rehabilitative alimony shall continue until modified further by court order, the
death of either party or until {date/event} __________________________________________,
whichever occurs first. The rehabilitative plan presented demonstrated the following:
_____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.

d. ______ Retroactive. Obligor shall pay retroactive alimony in the amount of $___________ for
the period of {date} _____________________, through {date} ________________________,
which shall be paid pursuant to paragraph 4 below.

3. Reasons for _____ Awarding _____Denying Modification of Alimony. The Court has considered all
of the following in awarding/denying the modification of alimony request:
a. The standard of living established during the marriage;
b. The duration of the marriage;
c. The age and the physical and emotional condition of each party;
d. The financial resources of each party, including, the nonmarital and the marital assets and
liabilities distributed to each;
e. The earning capacities, educational levels, vocational skills, and employability of the parties and
when applicable, the time necessary for either party to acquire sufficient education or training
to enable such party to find appropriate employment;
f. The contribution of each party to the marriage, including, but not limited to, services rendered
in homemaking, child care, education, and career building of the other party;
Florida Supreme Court Approved Family Law Form 12.993(c), Supplemental Final Judgment Modifying Alimony
(03/15)
- 837 -
g. The tax treatment and consequences to both parties of any alimony award, including the
designation of all or a portion of the payment as nontaxable, nondeductible payment;
h. All sources of income available to either party, including income available to either party
through investments of any assets held by that party, and
i. _____Any other factor necessary to do equity and justice between the parties {Explain}
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
____ Please indicate here if additional pages are attached.

4. Arrearage/Retroactive Alimony.

a. _____There is no alimony arrearage at the time of this Supplemental Final Judgment.
OR
b. _____The _____ Petitioner _____ Respondent shall pay to the other party the alimony
arrearage of:
$______________for retroactive alimony, as of {date} ______________________________;
$______________for previously ordered unpaid alimony, as of {date} __________________.
The total of $____________________ in alimony arrearage shall be repaid in the amount of
$_______________per month, payable _____ in accordance with Obligor’s employer’s payroll
cycle, and in any event at least once a month _____ other {explain} _____________________
__________________________________________________________________________
beginning {date} ________________________, until paid in full including statutory interest.

5. _____Life Insurance (to secure payment of support).
To secure the alimony obligations set forth in this judgment, Obligor shall maintain life insurance
coverage on his/her life naming Obligee as the sole irrevocable beneficiary, so long as
reasonably available. This insurance shall be in the amount of at least $___________________
and shall remain in effect until the obligation for alimony terminates.

6. _____Other provisions relating to modification of alimony, including any tax treatment and
consequences: ________________________________________________________
____________________________________________________________________________
_____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.

SECTION III. METHOD OF PAYMENT

1. Place of Payment

a. _____Obligor shall pay court-ordered support directly to either the State Disbursement Unit or
the central depository, as required by statute, along with any fee required by statute.

b. _____Both parties have requested that support payments not be directed through either the

Florida Supreme Court Approved Family Law Form 12.993(c), Supplemental Final Judgment Modifying Alimony
(03/15)
- 838 -
State Disbursement Unit or the central depository at this time; however, either party may
subsequently apply to the depository pursuant to section 61.08, Florida Statutes, to require
payments through either the State Disbursement Unit or the central depository.

2. Income Deduction.

a. _____Immediate. Obligor shall pay through income deduction, pursuant to a separate Income
Deduction Order which shall be effective immediately. Obligor is individually responsible for
paying this support obligation until all of said support is deducted from Obligor’s income. Until
support payments are deducted from Obligor’s paycheck, Obligor is responsible for making
timely payments directly to the State Disbursement Unit or the Obligee, as previously set forth
in this order.

b. _____Deferred. Income Deduction is ordered this day, but it shall not be effective until a
delinquency of $________________, or, if not specified, an amount equal to one month’s
obligation occurs. Income deduction is not being implemented immediately based on the
following findings:
There is (are) no minor or dependent child(ren) common to the parties,
AND
There is proof of timely payment of a previously ordered obligation without an Income
Deduction Order,
AND
_____ There is an agreement by the Obligor to advise the Title IV-D agency, the clerk of court,
and the Obligee of any change in Payor and/or health insurance
OR
_____ there is a signed written agreement providing an alternative arrangement between the
Obligor and the Obligee and, at the option of the IV-D agency, by the IV-D agency in IV-D cases
in which there is an assignment of support rights to the state, reviewed and entered in the
record by the court.

3. Bonus/one-time payments. _____ All _______% _____ No income paid in the form of a bonus or
other similar one-time payment, up to the amount of any arrearage of the remaining balance
thereof owed pursuant to this order, shall be forwarded to the Obligee pursuant to the payment
method prescribed above.

4. Other provisions relating to method of payment. _____________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.

SECTION IV. ATTORNEY’S FEES, COSTS, AND SUIT MONEY

1. _____ Petitioner’s _____ Respondent’s request(s) for attorney’s fees, costs, and suit money is (are)
denied because
_______________________________________________________________________________

Florida Supreme Court Approved Family Law Form 12.993(c), Supplemental Final Judgment Modifying Alimony
(03/15)
- 839 -
________________________________________________________________________________
________________________________________________________________________________.

2. _____ The Court finds there is a need for and an ability to pay attorney’s fees, costs, and suit money.
_____ Petitioner _____ Respondent is hereby ordered to pay to the other party $_______________
in attorney’s fees, and $_________________ in costs. The Court further finds that the attorney’s
fees awarded are based on the reasonable rate of $__________ per hour and ______________
reasonable hours. Other provisions relating to attorney’s fees, costs, and suit money are as follows:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________.

SECTION V. OTHER
1. Other Provisions: _______________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.

2. The Court reserves jurisdiction to modify and enforce this Supplemental Final Judgment.

3. Unless specifically modified by this Supplemental Final Judgment, the provisions of all final
judgments or orders in effect remain the same.

DONE AND ORDERED on __________________ in __________________________, Florida.

_________________________________
CIRCUIT JUDGE

I certify that a copy of the {name of document(s)} ___________________________________________
was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the parties and any entities
listed below on {date}___________________.

by__________________________________
{Clerk of court or designee}

____Petitioner (or his or her attorney)
____Respondent (or his or her attorney)
____Central Depository

Florida Supreme Court Approved Family Law Form 12.993(c), Supplemental Final Judgment Modifying Alimony
(03/15)
- 840 -
____State Disbursement Unit
____Other:_________________________

Florida Supreme Court Approved Family Law Form 12.993(c), Supplemental Final Judgment Modifying Alimony
(03/15)
- 841 -
IN THE CIRCUIT COURT OF THE___________________________JUDICIAL CIRCUIT,
IN AND FOR _______________________COUNTY, FLORIDA

Case No.: _______________________________
Division: ________________________________
________________________________,
Petitioner,

and

________________________________,
Respondent.

SUPPLEMENTAL TEMPORARY JUDGMENT MODIFYING PARENTING
ISSUES FOR CHILD(REN) OF A PARENT ACTIVATED, DEPLOYED,
OR TEMPORARILY ASSIGNED TO MILITARY SERVICE
This cause came before this Court on a Supplemental Petition for Temporary Modification of Custody or
Parenting Plan/Time-Sharing Schedule for Child(ren) of a Parent Activated, Deployed, or Temporarily
Assigned to Military Service. The Court, having reviewed the file, heard the testimony, and being
otherwise fully advised, makes these findings of fact and reaches these conclusions of law:

SECTION I. FINDINGS

1. The Court has jurisdiction over the subject matter and the parties.

2. The last order establishing or modifying parental responsibility, visitation, or time-sharing was
entered on {date} _______________________.

3. There is clear and convincing evidence that it is in the best interests of the minor child(ren) that the
current order establishing parental responsibility, visitation, and time-sharing be temporarily
modified as the _____ Mother _____ Father is activated, deployed, or temporarily assigned to
military service. Specifically:
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________.

SECTION II. TEMPORARY PARENTING PLAN ESTABLISHING PARENTAL RESPONSIBILITY AND TIME-
SHARING WITH DEPENDENT OR MINOR CHILD(REN)

Florida Supreme Court Approved Family Law Form 12.993(d), Supplemental Temporary Judgment Modifying
Parenting Issues for Child(ren) of a Parent Activated, Deployed, or Temporary Assigned to Military Service.
(03/15)
- 842 -
1. Jurisdiction. The Court has jurisdiction to determine parental responsibility, to establish or approve
a Parenting Plan, and time-sharing with regards to the parties’ minor child(ren) listed in paragraph 2
below.

3. Parenting Plan. The parties shall comply with the temporary Parenting Plan which is attached and
incorporated herein as Exhibit _____.

SECTION III. CHILD SUPPORT

1. Temporary Modification of Child Support.
{Choose one only}

a. _____The _____ Mother’s _____ Father’s current obligation to pay child support is:

_____ Abated
_____ Suspended
_____ Modified to $______________ per ________________.

b. _____The Court finds that there is a need for temporary modification of child support and
that the service member _____ Mother _____ Father (hereinafter Obligor) has the present
ability to pay child support. The amounts in the Child Support Guidelines Worksheet, Florida
Family Law Rules of Procedure Form 12.902(e), filed by the _____ Mother _____ Father are
correct
OR the Court makes the following findings:

The Mother’s net monthly income is $____________, (Child Support Guidelines ____ %).
The Father’s net monthly income is $_____________, (Child Support Guidelines____%).
Monthly child care costs are $________________.
Monthly health/dental insurance costs are $__________________.

2. Amount.
Child support established at the rate of $____________per month for the _______children
{total number of parties’ minor or dependent children} shall be paid commencing
___________________ {month, day, year} and terminating _______________________
Florida Supreme Court Approved Family Law Form 12.993(d), Supplemental Temporary Judgment Modifying
Parenting Issues for Child(ren) of a Parent Activated, Deployed, or Temporary Assigned to Military Service.
(03/15)
- 843 -
{month, day, year}. Child support shall be paid in the amount of $_____________ per
____________ {week, month, other} which is consistent with the Obligor’s current payroll cycle.

Upon the termination of the obligation of child support for one of the parties’ children, child
support in the amount of $___________for the remaining _______children {total number of
remaining children} shall be paid commencing _______________________________ {month,
day, year} and terminating ___________________________ {month, day, year}. This child
support shall be paid in the amount of $_________ per ______________ {week, month, other}
consistent with the Obligor’s current payroll cycle.

{Insert schedule for the child support obligation, including the amount, and commencement
and termination dates, for the remaining minor or dependent children, which shall be payable
as the obligation for each child ceases. Please indicate whether the schedule _____ appears
below or _____ is attached as part of this form.}
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.

The Obligor shall pay child support until all of the minor or dependent children: reach the age of
18; become emancipated, marry, join the armed services, die, or become self-supporting; or
until further order of the court or agreement of the parties. The child support obligation shall
continue beyond the age of 18 and until high school graduation for any child who is dependent
in fact, between the ages of 18 and 19, and is still in high school, performing in good faith with a
reasonable expectation of graduation before the age of 19.

If the child support ordered deviates from the guidelines by more than 5%, the factual findings
which support that deviation are: _________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________.

3. Arrearage/Retroactive Child Support.
{Choose one only}

a. _____There is no child support arrearage at the time of this Supplemental Temporary Judgment.
OR
b. _____The _____ Mother _____ Father shall pay to the other party the child support arrearage
of:
$___________ for retroactive child support, as of {date} __________________.
$___________ for previously ordered unpaid child support, as of {date} _________________.
The total of $___________ in child support arrearage shall be repaid in the amount of
Florida Supreme Court Approved Family Law Form 12.993(d), Supplemental Temporary Judgment Modifying
Parenting Issues for Child(ren) of a Parent Activated, Deployed, or Temporary Assigned to Military Service.
(03/15)
- 844 -
$___________, per month payable_____ in accordance with Obligor’s employer’s payroll cycle,
and in any event at least once a month _____ other {explain} _________________________
______________________________________________________________________________
beginning {date} ___________________________, until paid in full including statutory interest.

4. Insurance.

a. _____Health/Dental Insurance.
{Choose one only}
_____ The service member _____ Mother _____ Father shall enroll the child(ren) as a military
dependent(s) with DEERs, TriCare, or other similar benefits available to military dependents as
provided by the service member’s branch or service and federal regulations;
OR
______The _____ Mother _____ Father shall maintain _____ health and/or _____ dental
insurance for the parties’ minor child(ren), so long as it is reasonable in cost and accessible to
the child(ren). The party providing insurance shall be required to convey insurance cards
demonstrating said insurance to the other party;
OR
______ Health _____Dental insurance is not reasonable in cost or accessible to the
child(ren) at this time.

b. _____Reasonable and necessary uninsured medical/dental/prescription drug costs for the
minor child(ren) shall be assessed as follows:
_____ Shared equally by both parents.
_____ Prorated according to the child support guideline percentages.
_____ Other {explain}: ____________________________________________________________
______________________________________________________________________________
As to these uninsured medical/dental/prescription drug expenses, the party who incurs the
expense shall submit a request for reimbursement to the other party within 30 days, and the
other party, within 30 days of receipt, shall submit the applicable reimbursement for that
expense, according to the schedule of reimbursement set out in this paragraph.

5. ____Life Insurance (to secure payment of support). To secure the child support obligations in this
judgment, _____ Mother _____ Father _____Each party shall maintain life insurance, in an amount
of at least $____________, on _____ his life _____ her life _____ his/her life naming the _____
minor child(ren) as the beneficiary(ies) OR naming the _____ Mother _____ Father _____ other
{name} ____________________________________________ as Trustee for the minor child(ren),
so long as reasonably available. The obligation to maintain the life insurance coverage shall
continue until the youngest child turns 18, becomes emancipated, marries, joins the armed
services, dies, or otherwise becomes self-supporting.

6. _____IRS Income Tax Exemption(s). The assignment of any tax exemption(s) for the child(ren) shall

Florida Supreme Court Approved Family Law Form 12.993(d), Supplemental Temporary Judgment Modifying
Parenting Issues for Child(ren) of a Parent Activated, Deployed, or Temporary Assigned to Military Service.
(03/15)
- 845 -
be as follows: ____________________________________________________________________
________________________________________________________________________________.
Further, each party shall execute any and all IRS forms necessary to effectuate the provisions of this
paragraph.

7. Other provisions relating to child support: _____________________________________________
_________________________________________________________________________________
________________________________________________________________________________.

SECTION IV. METHOD OF PAYMENT

Obligor shall pay court-ordered child support and arrears, if any, as follows:

1. Place of Payment.

a. _____Obligor shall pay court-ordered support directly to either the State Disbursement Unit or
the central depository, as required by statute, along with any fee required by statute.

b. _____Both parties have requested and the court finds that it is in the best interests of the
child(ren) that support payments need not be directed through either the State Disbursement
Unit or the central depository at this time; however, either party may subsequently apply,
pursuant to section 61.13(1)(d)3, Florida Statutes, to require payments through the State
Disbursement Unit or the central depository.

2. Income Deduction.

b. _____Deferred. Income deduction is ordered this day, but it shall not be effective until a
delinquency of $______________, or, if not specified, an amount equal to one month’s
obligation occurs. Income deduction is not being implemented immediately based on the
following findings:
Income deduction is not in the best interests of the child(ren) because: {explain}
_____________________________________________________________________________
______________________________________________________________________________
AND
_____ There is proof of timely payment of a previously ordered obligation without an Income
Deduction Order,
Florida Supreme Court Approved Family Law Form 12.993(d), Supplemental Temporary Judgment Modifying
Parenting Issues for Child(ren) of a Parent Activated, Deployed, or Temporary Assigned to Military Service.
(03/15)
- 846 -
AND
_____ There is an agreement by the Obligor to advise the Title IV-D agency, clerk of court and
Obligee of any change in Payor and/or health insurance OR _____there is a signed written
agreement providing an alternative arrangement between the Obligor and the Obligee and, at
the option of the IV-D agency, by the IV-D agency in IV-D cases in which there is an assignment
of support rights to the state, reviewed and entered in the record by the court.

4. Other provisions relating to method of payment. _________________________________________
__________________________________________________________________________________
_________________________________________________________________________________.

SECTION V. ATTORNEY’S FEES, COSTS, AND SUIT MONEY

1. _____ Petitioner’s _____ Respondent’s request(s) for attorney’s fees, costs, and suit money is (are)
denied because ____________________________________________________________________
__________________________________________________________________________________.

2. ______ The Court finds there is a need for and an ability to pay attorney’s fees, costs, and suit
money. _____Petitioner _____ Respondent is hereby ordered to pay to the other party
$ ____________ in attorney’s fees, and $ ____ in costs. The Court further finds that the
attorney’s fees awarded are based on the reasonable rate of $ ____ per hour and
reasonable hours. Other provisions relating to attorney’s fees, costs, and suit money are
as follows: ________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________.

SECTION VI. OTHER

2. The Court reserves jurisdiction to modify and enforce this Supplemental Temporary Judgment.
Florida Supreme Court Approved Family Law Form 12.993(d), Supplemental Temporary Judgment Modifying
Parenting Issues for Child(ren) of a Parent Activated, Deployed, or Temporary Assigned to Military Service.
(03/15)
- 847 -
3. Unless specifically modified by this supplemental temporary judgment, the provisions of all final
judgments or orders in effect remain the same.

DONE AND ORDERED at _________________________, Florida, on ___________________.

_____________________________________________
CIRCUIT JUDGE

I certify that a copy of the {name of document(s)} ___________________________________________
was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the parties and any
entities listed below on {date}____________________.

______________________________________
by {clerk of court or designee}

_____Petitioner (or his or her attorney)
_____Respondent (or his or her attorney)
_____Central Depository
_____State Disbursement Unit
_____Other:_______________________

Case No.:
Division:
,
Husband,

and

,
Wife.

FINAL JUDGMENT FOR SUPPORT UNCONNECTED WITH DISSOLUTION OF
MARRIAGE WITH DEPENDENT OR MINOR CHILD(REN)

This cause came before this Court on a Petition for Support Unconnected with Dissolution of Marriage
under section 61.09, Florida Statutes. The Court, having reviewed the file and heard the testimony,
makes these findings of fact and reaches these conclusions of law:

1. The Court has jurisdiction over the subject matter and the parties.

2. The following child(ren) are common to the parties:

Name Birth date

SECTION I. ALIMONY

1. _____The Court denies the request(s) for alimony.
OR
2. _____The Court finds that there is a need for alimony and that _____Husband _____Wife
has/had the ability to support his/her spouse and has failed to do so. ____Husband
____Wife(hereinafter Obligor) has the present ability to pay alimony as follows:
{Indicate all that apply}

a. _____Permanent Periodic.

Florida Supreme Court Approved Family Law Form 12.994(a), Final Judgment for Support Unconnected with
Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
- 849 -
1. The court finds that no other form of alimony is fair and reasonable under the
circumstances of the parties.
2. As a marriage of {choose only one}:

_____Long Duration (17 years or greater) alimony is appropriate upon consideration
of all relevant factors;

_____Moderate Duration (greater than 7 years but less than 17) alimony is
appropriate based upon clear and convincing evidence after consideration of all
relevant factors; or

_____Short Duration (less than 7 years) alimony is appropriate based upon the
following exceptional circumstances:_________________________________
_______________________________________________________________
_______________________________________________________________ .

3. Obligor shall pay permanent periodic alimony to Obligee in the amount of $ ______
per month, payable _____ in accordance with Obligor’s employer’s payroll cycle, and in
any event, at least once a month or _____ other: {explain}________________________
beginning {date} _______________. This alimony shall continue until modified by court
order, the death of either party, or remarriage of Obligee, whichever occurs first. The
alimony may be modified or terminated based upon either a substantial change in
circumstances or the existence of a supportive relationship in accordance with section
61.14, Florida Statutes.

b._____Bridge-the-Gap. Obligor shall pay bridge-the-gap alimony to Obligee in the amount of
$___________ per month, payable _____ in accordance with Obligor’s employer’s payroll cycle,
and in any event, at least once a month, or _____ other: {explain}________________________
beginning {date}___________ _________ and continuing until {date}________________ ______
{a period not to exceed two (2) years}, death of either party or remarriage of Obligee.

c._____Rehabilitative. Obligor shall pay rehabilitative alimony to Obligee in the amount of
$ per month, payable _____ in accordance with Obligor’s employer’s payroll cycle,
and in any event, at least once a month, or _____ other {explain} _________________________
beginning {date} ____. This rehabilitative alimony shall continue until modified
by court order, the death of either party or until {date/event} _________________________,
whichever occurs first. The rehabilitative plan presented demonstrated the following: ________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________.

d.__ ___Durational. Obligor shall pay durational alimony to Obligee in the amount of $________
per month, payable _____ in accordance with Obligor’s employer’s payroll cycle, and in any event,

Florida Supreme Court Approved Family Law Form 12.994(a), Final Judgment for Support Unconnected with
Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
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at least once a month, or _____ other: {explain}______________________________ _ beginning
{date}_______________________ and terminating on {date}_________________________, the
death of either party, remarriage of Obligee or until modified by court order in accordance with
section 61.08(7),Florida Statutes; whichever occurs first.

e._____ Lump Sum. Obligor shall pay lump sum alimony to Obligee in the amount of $_________
which shall be paid as follows:______________________________________________________.

f._____ Retroactive. Obligor shall pay retroactive alimony in the amount of $ _____________
for the period of {date} , through {date} , which shall be
paid pursuant to paragraph 4 below.

3. Reasons for _____ Awarding _____ Denying Alimony. The Court has considered all of the
following in awarding/denying alimony:
a. The standard of living established during the marriage;
b. The duration of the marriage;
c. The age and the physical and emotional condition of each party;
d. The financial resources of each party, including the nonmarital and the marital assets and
liabilities distributed to each;
e. The earning capacities, educational levels, vocational skills, and employability of the parties
and, when applicable, the time necessary for either party to acquire sufficient education or
training to enable such party to find appropriate employment;
f. The contribution of each party to the marriage, including, but not limited to, services
rendered in homemaking, child care, education, and career building of the other party;
g. The responsibilities each party will have with regard to any minor children they have in
common;
h. The tax treatment and consequences to both parties of any alimony award, including the
designation of all or a portion of the payment as a nontaxable, nondeductible payment;
i. All sources of income available to either party, including income available to either party
through investments of any asset held by that party; and
j. Any other factor necessary to do equity and justice between the parties: {Explain}

______ Please indicate here if additional pages are attached.

4. Arrearage/Retroactive Alimony.

a. _____There is no alimony arrearage at the time of this Final Judgment.

OR
b. _____ Respondent shall pay to Petitioner the alimony arrearage of:

Florida Supreme Court Approved Family Law Form 12.994(a), Final Judgment for Support Unconnected with
Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
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$ for retroactive alimony, as of {date} .
$ for previously ordered unpaid alimony, as of {date} .
The total of $ in alimony arrearage shall be repaid in the amount of $
per month, payable _____ in accordance with Obligor’s employer’s payroll cycle, and in any
event, at least once a month _____ other {explain} __________________________
beginning {date} __________, until paid in full including statutory interest.

5. _____Life Insurance (to secure payment of support). To secure the alimony obligations set
forth in this judgment, Obligor shall maintain life insurance on his/her life naming Obligee as
the sole irrevocable beneficiary, so long as reasonably available. This insurance shall be in the
amount of at least $ __________ and shall remain in effect until the obligation for alimony
terminates.

6. _____ Other provisions relating to alimony including any tax treatment and consequences:

a. The award of alimony _____ does not _____ does leave the Obligor with significantly
less net income than the net income of the recipient/Obligee. If yes, the court finds the
following exceptional circumstances:_________________________________________
_______________________________________________________________________
________________________________________________________________________.

b. Other:__________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________.

SECTION II. CHILD SUPPORT
1. The Court finds that there is a need for child support and that the _____ Mother _____ Father
(hereinafter Obligor) has the present ability to pay child support. The amounts in the Child
Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e), filed by
the _____ Mother _____Father are correct OR the Court makes the following findings:

The Mother’s net monthly income is $ ___________, (Child Support Guidelines _ %).
The Father’s net monthly income is $ ____, (Child Support Guidelines _____%).
Monthly child care costs are $ .
Monthly health/dental insurance costs are $ .

2. Amount.
Child support established at the rate of $____________ per month for the______children {total
number of parties’ minor or dependent children} shall be paid commencing _______________
{month, day, year} and terminating ___________________ {month, day, year}. Child support

Florida Supreme Court Approved Family Law Form 12.994(a), Final Judgment for Support Unconnected with
Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
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shall be paid in the amount of $________ per ______________ {week, month, other} which is
consistent with the Obligor’s current payroll cycle.

Upon the termination of the obligation of child support for one of the parties’ children, child
support in the amount of $__________for the remaining ______ children {total number of
remaining children} shall be paid commencing ____________________________{month, day,
year} and terminating________________________________{month, day, year}. This child
support shall be paid in the amount of $_______ _per_______________ {week, month, other}
consistent with the Obligor’s current payroll cycle.

{Insert schedule for the child support obligation, including the amount, and commencement
and termination dates, for the remaining minor or dependent children, which shall be payable
as the obligation for each child ceases. Please indicate whether the schedule _____appears
below or _____ is attached as part of this form.}
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.

The Obligor shall pay child support until all of the minor or dependent children: reach the age of
18; become emancipated, marry, join the armed services, die, or become self-supporting; or
until further order of the court or agreement of the parties. The child support obligation shall
continue beyond the age of 18 and until high school graduation for any child who is dependent
in fact, between the ages of 18 and 19, and is still in high school, performing in good faith with a
reasonable expectation of graduation before the age of 19.

If the child support ordered deviates from the guidelines by more than 5%, the factual findings
which support that deviation are:

3. Arrearage/Retroactive Child Support.

a. _____ There is no child support arrearage at the time of this Final Judgment.
OR
b. _____ The _____ Mother _____ Father shall pay to the other party the child support for
previously ordered unpaid child support, as of {date} ____________________________.
The total of $ __________ of child support arrearage shall be repaid in the amount of
$ ____ per month, payable _____ in accordance with Obligor’s employer’s payroll
cycle, and in any event, at least once a month _____ other {explain} __________________
beginning {date} _________, until paid in full including statutory interest.

Florida Supreme Court Approved Family Law Form 12.994(a), Final Judgment for Support Unconnected with
Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
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4. Insurance.
{Indicate all that apply}

a. _____ Health/Dental Insurance. _____ Mother _____ Father shall be required to
maintain _____ health and/or _____dental insurance for the parties’ minor child(ren), so
long as it is reasonable in cost and accessible to the child(ren). The party providing insurance
shall be required to convey insurance cards demonstrating said insurance to the other party.
OR
_____ Health _____ Dental insurance is either not reasonable in cost or accessible to the
children at this time.

As to these uninsured medical/dental/prescription drug expenses, the party who incurs the
expense shall submit a request for reimbursement to the other party within 30 days, and
the other party, within 30 days of receipt, shall submit the applicable reimbursement for
that expense, according to the schedule of reimbursement set out in this paragraph.

5. _____Life Insurance (to secure payment of support). To secure the child support obligations in
this judgment, _____ Mother _____ Father _____ Each party shall maintain life insurance, in an
amount of at least $ , on _____ his life _____ her life _____ his/her life naming the
_____ minor child(ren) as the beneficiary(ies) OR naming _____ Mother _____ Father
_____ other {name}__________________________________________ as Trustee for the minor
child(ren). The obligation to maintain the life insurance coverage shall continue until the
youngest child turns 18, becomes emancipated, marries, joins the armed services, dies, or
becomes self-supporting.

7. Other provisions relating to child support: ___________________________________________

SECTION III. METHOD OF PAYMENT
Obligor shall pay court-ordered child support/alimony and arrears, if any, as follows:

Florida Supreme Court Approved Family Law Form 12.994(a), Final Judgment for Support Unconnected with
Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
- 854 -
1. Place of Payment.

a. _____ Obligor shall pay court-ordered support directly to either the State Disbursement Unit
or the central depository, as required by statute, along with any fee required by statute.

b. _____ Both parties have requested and the court finds that it is in the best interests of the
child(ren) that support payments need not be directed through either the State
Disbursement Unit or the central depository at this time; however, either party may
subsequently apply, pursuant to section 61.08 or 61.13, Florida Statutes, to require
payments through either the State Disbursement Unit or the central depository.

2. Income Deduction.

a. _____Immediate. Obligor shall pay through income deduction, pursuant to a separate
Income Deduction Order which shall be effective immediately. Obligor is individually
responsible for paying this support obligation until all of said support is deducted from
Obligor’s income. Until support payments are deducted from Obligor’s paycheck, Obligor is
responsible for making timely payments directly to the State Disbursement Unit or the
Obligee, as previously set forth in this order.

b. _____ Deferred. Income deduction is ordered this day, but it shall not be effective until a
delinquency of $ ______, or, if not specified, an amount equal to one month’s
obligation occurs. Income deduction is not being implemented immediately based on the
following findings: Income deduction is not in the best interests of the child(ren) because:
{explain} ___________________________________________________________________
,
AND
_____ there is proof of timely payment of a previously ordered obligation without an
Income Deduction Order in cases of modification,
AND
_____ there is an agreement by the Obligor to advise the Title IV-D agency, clerk of court,
and Obligee of any change in Payor and/or health insurance
OR
_____there is a signed written agreement providing an alternative arrangement between
the Obligor and the Obligee and, at the option of the IV-D agency, by the IV-D agency in IV-D
cases in which there is an assignment of support rights to the state, reviewed and entered in
the record by the court.

Florida Supreme Court Approved Family Law Form 12.994(a), Final Judgment for Support Unconnected with
Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
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4. Other provisions relating to method of payment. _____________________________________

SECTION IV. ATTORNEY’S FEES, COSTS, AND SUIT MONEY
1. _____ Husband’s _____ Wife’s request(s) for attorney’s fees, costs, and suit money is (are)
denied because: ________________________________________________________________
.

2. _____ The Court finds there is a need for and an ability to pay attorney’s fees, costs, and suit
money. _____Husband _____ Wife is hereby ordered to pay to the other party $ _____
in attorney’s fees, and $ _____ in costs. The Court further finds that the attorney’s fees
awarded are based on the reasonable rate of $____________per hour and ___ reasonable
hours. Other provisions relating to attorney’s fees, costs, and suit money are as follows:
______________________________________________________________________________

SECTION V. OTHER PROVISIONS
1. Other Provisions:
_______________________________________________________________

2. The Court reserves jurisdiction to modify and enforce this Final Judgment.

DONE AND ORDERED at _____, Florida, on _______________________ .

CIRCUIT JUDGE

I certify that a copy of the {name of document(s)} _________________________________________ was
( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the parties and any entities
listed below on {date}_______________________.

Florida Supreme Court Approved Family Law Form 12.994(a), Final Judgment for Support Unconnected with
Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
- 856 -
______________________________________
By: {Clerk of court or designee}

_____Husband (or his attorney)
_____Wife (or her attorney)
_____Central Depository
_____State Disbursement Unit
_____Other:

Florida Supreme Court Approved Family Law Form 12.994(a), Final Judgment for Support Unconnected with
Dissolution of Marriage with Dependent or Minor Child(ren) (03/15)
- 857 -
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND _________ COUNTY, FLORIDA

In re the Marriage of:

Case No.:
Division:
______________,
Husband,

and

____________,
Wife.

FINAL JUDGMENT FOR SUPPORT
UNCONNECTED WITH DISSOLUTION OF MARRIAGE
WITH NO DEPENDENT OR MINOR CHILD(REN)

2. The parties have no minor or dependent children in common, and the wife is not pregnant.

SECTION I. ALIMONY

1. _____The Court denies the request(s) for alimony.
OR
2. _____The Court finds that there is a need for alimony and that ____Husband ____Wife has/had
the ability to support his/her spouse and has failed to do so. _____Husband
_____Wife(hereinafter Obligor) has the present ability to pay alimony as follows:
{Indicate all that apply}

a. ______ Permanent Periodic.

Florida Supreme Court Approved Family Law Form 12.994(b), Final Judgment for Support Unconnected with
Dissolution of Marriage with No Dependent or Minor Child(ren) (03/15)

- 858 -
1. The court finds that no other form of alimony is fair and reasonable under the
circumstances of the parties.

2. As a marriage of (choose one only):

_____Long Duration (17 years or greater) alimony is appropriate upon consideration of
all relevant factors;

_____Moderate Duration (greater than 7 years but less than 17) alimony is appropriate
based upon clear and convincing evidence after consideration of all relevant
factors; or

_____ Short Duration (less than 7 years) alimony is appropriate based upon the
following exceptional circumstances:_______________________________
_____________________________________________________________
_______________________________________________________________
____________________________________________________________ .

3. Obligor shall pay permanent periodic alimony to Obligee in the amount of $
per month, payable_____ in accordance with Obligor’s employer’s payroll cycle, and in any
event, at least once a month, or _____ other: {explain}_______________________________
beginning {date} _________. This alimony shall continue until modified by court
order, the death of either party, or remarriage of Obligee, whichever occurs first. The
alimony may be modified or terminated based upon either a substantial change in
circumstances, or a supportive relationship in accordance with section 61.14, Florida
Statutes.

b. _____Bridge-the-Gap. Obligor shall pay bridge-the-gap alimony to Obligee in the amount of
$______per month, payable_____ in accordance with Obligor’s employer’s payroll cycle,
beginning {date}________________and continuing until {date}___________________ {a period
not to exceed two years}, remarriage of Obligee, or death of either party, whichever occurs first.

c. _____Rehabilitative. Obligor shall pay rehabilitative alimony to Obligee in the amount of
$ ______ per month, payable _____ in accordance with Obligor’s employer’s payroll cycle, and
in any event, at least once a month _____ other {explain}________________________.
beginning {date} _________.This rehabilitative alimony shall continue until modified by
court order, the death of either party or until {date/event} _____________________________
_____________________________________________________________________________.
whichever occurs first. The rehabilitative plan presented demonstrated the following: ________
_____________________________________________________________________________.

d. ______Durational. Obligor shall pay durational alimony to Obligee in the amount of
$____________per month payable _____ in accordance with Obligor’s employer’s payroll cycle,

Florida Supreme Court Approved Family Law Form 12.994(b), Final Judgment for Support Unconnected with
Dissolution of Marriage with No Dependent or Minor Child(ren) (03/15)

- 859 -
and in any event, at least once a month, or _____ other {explain}______________________
beginning {date}________________and terminating on {date }________________________,
remarriage of the Obligee, death of either party, or until modified by court order in accordance
with section 61.08(7), Florida Statutes; whichever occurs first.

e. _____Lump Sum. Obligor shall pay lump sum alimony to Obligee in the amount of
$_________which shall be paid as follows:___________________________________________
.

f.______Retroactive. Obligor shall pay retroactive alimony in the amount of $ ____
for the period of {date} __________, through {date} ____________, which
shall be paid pursuant to paragraph 4 below.

3. Reasons for _____ Awarding _____ Denying Alimony. The Court has considered all of the
following in awarding/denying alimony:
a. The standard of living established during the marriage;
b. The duration of the marriage;
c. The age and the physical and emotional condition of each party;
d. The financial resources of each party, including the nonmarital and the marital assets and
liabilities distributed to each;
e. The earning capacities, educational levels, vocational skills, and employability of the parties
and, when applicable, the time necessary for either party to acquire sufficient education or
training to enable such party to find appropriate employment;
f. The contribution of each party to the marriage, including, but not limited to, services rendered
in homemaking, child care, education, and career building of the other party;
g. The tax treatment and consequences to both parties of any alimony award, including the
designation of all or a portion of the payment as nontaxable, nondeductible payment;
h. All sources of income available to either party, including income available to either party
through investments of any asset held by the party; and
i. Any other factor necessary to do equity and justice between the parties {Explain}

.
______ Please indicate here if additional pages are attached.

4. Arrearage/Retroactive Alimony.

a. _____There is no alimony arrearage at the time of this Final Judgment.
OR
b._____Respondent shall pay to Petitioner the alimony arrearage of:

Florida Supreme Court Approved Family Law Form 12.994(b), Final Judgment for Support Unconnected with
Dissolution of Marriage with No Dependent or Minor Child(ren) (03/15)

- 860 -
$ for retroactive alimony, as of {date} __________.
$ for previously ordered unpaid alimony, as of {date} ________.
The total of $ _ in alimony arrearage shall be repaid in the amount of
$ per month, payable _____ in accordance with Obligor’s employer’s payroll cycle,
and in any event at least once a month, _____ or other: {explain}_________________________

beginning {date} _______________, until paid in full including statutory interest.

5. ______Life Insurance (to secure payment of support). To secure the alimony obligations set
forth in this judgment, Obligor shall maintain life insurance coverage on his/her life naming
Obligee as the sole irrevocable beneficiary, so long as reasonably available. This insurance shall
be in the amount of at least $ ________ and shall remain in effect until the obligation for
alimony terminates.

6. ______Other provisions relating to alimony including any tax treatment and consequences:

a. The award of alimony _____ does not _____ does leave the Obligor with significantly less net
income than the net income of the recipient/Obligee. If yes, the court finds the following
exceptional circumstances:________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.

b. Other _______________________________________________________________________
______________________________________________________________________________
.

SECTION II. METHOD OF PAYMENT
Obligor shall pay court-ordered alimony and arrears, if any, as follows:

1. Place of Payment

a._____Obligor shall pay court-ordered support directly to either the State Disbursement Unit or
the central depository, as required by statute, along with any fee required by statute.

b._____ Both parties have requested and the court finds that support payments need not be
directed through either the State Disbursement Unit or the central depository at this time;
however, either party may subsequently apply, pursuant to section 61.13(1)(d)3, Florida
Statutes, to require payments through either the State Disbursement Unit or the central
depository.

Florida Supreme Court Approved Family Law Form 12.994(b), Final Judgment for Support Unconnected with
Dissolution of Marriage with No Dependent or Minor Child(ren) (03/15)

- 861 -
2. Income Deduction.

b._____Deferred. Income Deduction is ordered this day, but it shall not be effective until a
delinquency of $ , or, if not specified, an amount equal to one month’s obligation
occurs. Income deduction is not being implemented immediately based on the following
findings:
There are no minor child(ren) common to the parties,
AND
There is proof of timely payment of a previously ordered obligation without an income
deduction order in cases of modification,
AND
_____ There is an agreement by the Obligor to advise the Title IV-D agency, clerk of court, and
Obligee of any change in Payor and/or health insurance
OR
_____ there is a signed written agreement providing an alternative arrangement between the
Obligor and the Obligee and, at the option of the IV-D agency, by the IV-D agency in IV-D cases
in which there is an assignment of support rights to the state, reviewed and entered in the
record by the court.

3. Bonus/One-Time Payments. _____ All % _____ No income paid in the form of a bonus
or other similar one-time payment, up to the amount of any arrearage or the remaining balance
thereof owed pursuant to this order, shall be forwarded to the Obligee pursuant to the payment
method prescribed above.

4. Other provisions relating to method of payment:

SECTION III. ATTORNEY’S FEES, COSTS, AND SUIT MONEY
1. _____ Husband’s _____ Wife’s request(s) for attorney’s fees, costs, and suit money is (are)
denied because_________________________________________________________________
.

2. The Court finds there is a need for and an ability to pay attorney’s fees, costs, and suit

Florida Supreme Court Approved Family Law Form 12.994(b), Final Judgment for Support Unconnected with
Dissolution of Marriage with No Dependent or Minor Child(ren) (03/15)

- 862 -
money. _____Husband _____Wife is hereby ordered to pay to the other party $ ___
in attorney’s fees, and $ __ in costs. The Court further finds that the attorney’s fees
awarded are based on the reasonable rate of $ _______ per hour and ___ reasonable
hours. Other provisions relating to attorney’s fees, costs, and suit money are as follows:

SECTION IV. OTHER PROVISIONS
1. Other Provisions.

2. The Court reserves jurisdiction to modify and enforce this Final Judgment.

DONE AND ORDERED on _____________________ in ___________________________, Florida.

CIRCUIT JUDGE

I certify that a copy of the {name of document(s)} ________________________________________ was
( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand-delivered to the parties and any entities
listed below on {date}___________________.

by__________________________________
{Clerk of court or designee}

______Husband (or his attorney)
______Wife (or her attorney)

Florida Supreme Court Approved Family Law Form 12.994(b), Final Judgment for Support Unconnected with
Dissolution of Marriage with No Dependent or Minor Child(ren) (03/15)

- 863 -
______Central Depository
______State Disbursement Unit
______Other:

Florida Supreme Court Approved Family Law Form 12.994(b), Final Judgment for Support Unconnected with
Dissolution of Marriage with No Dependent or Minor Child(ren) (03/15)

- 864 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.995(a)
PARENTING PLAN (03/15)

When should this form be used?

A Parenting Plan is required in all cases involving time-sharing with minor child(ren), even when time-
sharing is not in dispute. The Parenting Plan must be developed and agreed to by the parents and
approved by the court. If the parties cannot agree to a Parenting Plan or if the parents agreed to a plan
that is not approved by the court, a Parenting Plan will be established by the court with or without the
use of parenting plan recommendations. This form or a similar form should be used in the development
of a Parenting Plan. If the case involves supervised time-sharing, the Supervised/Safety Focused
Parenting Plan, Florida Supreme Court Approved Family Law Form 12.995(b) or a similar form should be
used. If the case involves relocation, pursuant to Section 61.13001, Florida Statutes, then a
Relocation/Long Distance Parenting Plan, Florida Supreme Court Approved Family Law Form 12.995(c)
or a similar form should be used.

This form should be typed or printed in black ink. Please either delete or strike-through terms or
paragraphs that are inappropriate or inapplicable to your agreement. If an agreement has been reached,
both parties must sign the Parenting Plan and have their signatures witnessed by a notary public or
deputy clerk. After completing this form, you should file the original with the clerk of the circuit court
in the county where the petition was filed and keep a copy for your records. You should then refer to
the instructions for your petition, answer, or answer and counterpetition concerning the procedures for
setting a hearing or trial (final hearing). If the parents have not reached an agreement, a proposed
Parenting Plan may be filed by either parent at the time of or any time prior to the final hearing. If an
agreed Parenting Plan is not filed by the parties, the court shall establish a Plan.

IMPORTANT INFORMATION REGARDING E-FILING

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions for Florida Supreme Court Approved Family Law Form 12.995(a), Parenting Plan (03/15)
- 865 -
circumstances. You must strictly comply with the format requirements set forth in the Rules of Judicial
Administration.

Where can I look for more information?

Special notes...

At a minimum, the Parenting Plan must describe in adequate detail:
 How the parties will share and be responsible for the daily tasks associated with the upbringing
of the child(ren),
 The time-sharing schedule arrangements that specify the time that the minor child(ren) will
spend with each parent,
 A designation of who will be responsible for any and all forms of health care, school-related
matters, including the address to be used for school-boundary determination and registration, other
activities, and
 The methods and technologies that the parents will use to communicate with the child(ren).

The best interests of the child(ren) is the primary consideration in the Parenting Plan. In creating the
Parenting Plan, all circumstances between the parents, including their historic relationship, domestic
violence, and other factors must be taken into consideration. Determination of the best interests of the
child(ren) shall be made by evaluating all of the factors affecting the welfare and interest of the
particular minor child(ren) and the circumstances of that family, as listed in section 61.13(3), Florida
Statutes, including, but not limited to:

 The demonstrated capacity and disposition of each parent to facilitate and encourage a close and
continuing parent-child relationship, to honor the time-sharing schedule, and to be reasonable

Instructions for Florida Supreme Court Approved Family Law Form 12.995(a), Parenting Plan (03/15)
- 866 -
when changes are required;
 The anticipated division of parental responsibilities after the litigation, including the extent to
which parental responsibilities will be delegated to third parties;
 The demonstrated capacity and disposition of each parent to determine, consider, and act upon
the needs of the child(ren) as opposed to the needs or desires of the parent;
 The length of time the child(ren) has lived in a stable, satisfactory environment and the
desirability of maintaining continuity;
 The geographic viability of the parenting plan, with special attention paid to the needs of school-
age children and the amount of time to be spent traveling to effectuate the parenting plan. This factor
does not create a presumption for or against relocation of either parent with a child(ren);
 The moral fitness of the parents;
 The mental and physical health of the parents;
 The home, school, and community record of the child(ren);
 The reasonable preference of the child(ren), if the court deems the child(ren) to be of sufficient
intelligence, understanding, and experience to express a preference;
 The demonstrated knowledge, capacity, and disposition of each parent to be informed of the
circumstances of the minor child(ren), including, but not limited to, the child(ren)’s friends, teachers,
medical care providers, daily activities, and favorite things;
 The demonstrated capacity and disposition of each parent to provide a consistent routine for
the child(ren), such as discipline, and daily schedules for homework, meals, and bedtime;
 The demonstrated capacity of each parent to communicate with and keep the other parent
informed of issues and activities regarding the minor child(ren), and the willingness of each parent to
adopt a unified front on all major issues when dealing with the child(ren);
 Evidence of domestic violence, sexual violence, child abuse, child abandonment, or child neglect,
regardless of whether a prior or pending action relating to those issues has been brought. If the court
accepts evidence of prior or pending actions regarding domestic violence, sexual violence, child abuse,
child abandonment, or child neglect, the court must specifically acknowledge in writing that such
evidence was considered when evaluating the best interests of the child(ren);
 Evidence that either parent has knowingly provided false information to the court regarding any
prior or pending action regarding domestic violence, sexual violence, child abuse, child abandonment, or
child neglect;
 The particular parenting tasks customarily performed by each parent and the division or parental
responsibilities before the institution of litigation and during the pending litigation, including the extent
to which parenting responsibilities were undertaken by third parties;
 The demonstrated capacity and disposition of each parent to participate and be involved in the
child(ren)’s school and extracurricular activities;
 The demonstrated capacity and disposition of each parent to maintain an environment for the
child(ren) which is free from substance abuse;
 The capacity and disposition of each parent to protect the child(ren) from the ongoing litigation
as demonstrated by not discussing the litigation with the child(ren), not sharing documents or electronic
media related to the litigation with the child(ren), and refraining from disparaging comments about the
other parent to the child)ren); and
 The developmental stages and needs of the child(ren) and the demonstrated capacity and

Instructions for Florida Supreme Court Approved Family Law Form 12.995(a), Parenting Plan (03/15)
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disposition of each parent to meet the child(ren)’s developmental needs.

This standard form does not include every possible issue that may be relevant to the facts of your case.
The Parenting Plan should be as detailed as possible to address the time-sharing schedule. Additional
provisions should be added to address all of the relevant factors. The parties should give special
consideration to the age and needs of each child.

In developing the Parenting Plan, you may wish to consult or review other materials which are available
at your local library, law library or through national and state family organizations.

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

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IN THE CIRCUIT COURT OF THE _____________________ JUDICIAL CIRCUIT
IN AND FOR _________________ COUNTY, FLORIDA

Case No: ___________________

Division: _____________________

_______________________________
Mother
and
_______________________________
Father

PARENTING PLAN
This parenting plan is: {Choose only one}
_____A Parenting Plan submitted to the court with the agreement of the parties.
_____A proposed Parenting Plan submitted by or on behalf of:
{Parent’s Name}____________________________________________.
_____A Parenting Plan established by the court.

This parenting plan is: {Choose only one}
_____A final Parenting Plan established by the court.
_____A temporary Parenting Plan established by the court.
_____A modification of a prior final Parenting Plan or prior final order.

I. PARENTS
Mother
Name:__________________________________________________________________
Address: ________________________________________________________________
Telephone Number: ______________________________________________________
E-Mail: _________________________________________________________________
_____ Address Unknown: {Please indicate here if mother’s address is unknown}
_____ Address Confidential: {Please indicate here if mother’s address and phone numbers are
confidential pursuant to either a _____ Final Judgment for Protection Against Domestic Violence,
or _____ other court order ______________________________________________}.

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_____ Address Unknown: {Please indicate here if father’s address is unknown}
_____ Address Confidential: {Please indicate here if father’s address and phone numbers are
confidential pursuant to either a _____ Final Judgment for Protection Against Domestic Violence
or _____ other court order__________________________________________________.}

II. CHILDREN: This parenting plan is for the following child(ren) born to, or adopted by the parties:
(add additional lines as needed)
Name Date of Birth
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

III. JURISDICTION

The United States is the country of habitual residence of the child(ren).

The State of Florida is the child(ren)’s home state for the purposes of the Uniform Child Custody
Jurisdiction and Enforcement Act.

This Parenting Plan is a child custody determination for the purposes of the Uniform Child Custody
Jurisdiction and Enforcement Act, the International Child Abduction Remedies Act, 42 U.S.C.
Sections 11601 et seq., the Parental Kidnapping Prevention Act, and the Convention on the Civil
Aspects of International Child Abduction enacted at the Hague on October 25, 1980, and for all
other state and federal laws.

Other: ___________________________________________________________________________.

IV. PARENTAL RESPONSIBILITY AND DECISION MAKING

4. Parental Responsibility {Choose only one}

_____ Shared Parental Responsibility.
It is in the best interests of the child(ren) that the parents confer and jointly make all
major decisions affecting the welfare of the child(ren). Major decisions include, but are
not limited to, decisions about the child(ren)’s education, healthcare, and other
responsibilities unique to this family.

_____ Shared Parental Responsibility with Decision Making Authority

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It is in the best interests of the child(ren) that the parents confer and attempt to agree
on the major decisions involving the child(ren). If the parents are unable to agree, the
authority for making major decisions regarding the child(ren) shall be as follows:

Education/Academic decisions _____ Mother _____ Father
Non-emergency health care _____ Mother _____ Father
Other: {Specify}______________ _____ Mother _____ Father
___________________________ _____ Mother _____ Father
___________________________ _____ Mother _____ Father

_____ Sole Parental Responsibility:
It is in the best interests of the child(ren) that the ____ Mother ____ Father shall have
sole authority to make major decisions for the child(ren.) It is detrimental to the
child(ren) to have shared parental responsibility.

5. Day-to-Day Decisions
Unless otherwise specified in this plan, each parent shall make decisions regarding day-to-
day care and control of each child while the child is with that parent. Regardless of the
allocation of decision making in the parenting plan, either parent may make emergency
decisions affecting the health or safety of the child(ren) when the child is residing with that
parent. A parent who makes an emergency decision shall share the decision with the other
parent as soon as reasonably possible.

6. Extra-curricular Activities {Indicate all that apply}

a._____Either parent may register the child(ren) and allow them to participate in the activity
of the child(ren)’s choice.

b._____The parents must mutually agree to all extra-curricular activities.

c._____ The parent with the minor child(ren) shall transport the minor child(ren) to
and/or from all mutually agreed upon extra-curricular activities, providing all necessary
uniforms and equipment within the parent’s possession.

d._____ The costs of the extra-curricular activities shall be paid by:
Mother ______% Father ________ %

e._____ The uniforms and equipment required for the extra-curricular activities shall be
paid by: Mother _______ % Father ________%

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f._____ Other:
{Specify}_____________________________________________________
________________________________________________________.

V. INFORMATION SHARING. Unless otherwise indicated or ordered by the Court:

Unless otherwise prohibited by law, each parent shall have access to medical and school records
and information pertaining to the child(ren) and shall be permitted to independently consult
with any and all professionals involved with the child(ren). The parents shall cooperate with
each other in sharing information related to the health, education, and welfare of the child(ren)
and they shall sign any necessary documentation ensuring that both parents have access to said
records.

Each parent shall be responsible for obtaining records and reports directly from the school and
health care providers.

Both parents have equal rights to inspect and receive governmental agency and law
enforcement records concerning the child(ren).

Both parents shall have equal and independent authority to confer with the child(ren)’s
school, day care, health care providers, and other programs with regard to the child(ren)’s
educational, emotional, and social progress.

Both parents shall be listed as “emergency contacts” for the child(ren).

Each parent has a continuing responsibility to provide a residential, mailing, and contact address
and contact telephone number to the other parent. Each parent shall notify the other parent in
writing within 24 hours of any changes. Each parent shall notify the court in writing within seven
(7) days of any changes.

Other: _________________________________________________________________
________________________________________________________________.

VI. SCHEDULING

1. School Calendar
If necessary, on or before ______________ of each year, both parents should obtain a
copy of the school calendar for the next school year. The parents shall discuss the
calendars and the time-sharing schedule so that any differences or questions can be
resolved.

Florida Supreme Court Approved Family Law Form 12.995(a), Parenting Plan (03/15)
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The parents shall follow the school calendar of: {Indicate all that apply}
a._____the oldest child
b._____the youngest child
c._____ _________________ County
d._____ _________________ School

3. Schedule Changes {Indicate all that apply}

a._____A parent making a request for a schedule change will make the request as soon
as possible, but in any event, except in cases of emergency, no less than _____________
__________________before the change is to occur.

b._____A parent requesting a change of schedule shall be responsible for any additional
child care, or transportation costs caused by the change.

c._____Other {Specify}____________________________________________________.

VII. TIME-SHARING SCHEDULE

1. Weekday and Weekend Schedule
The following schedule shall apply beginning on ________________________ with the
_____ Mother _____ Father and continue as follows:

The child(ren) shall spend time with the Mother on the following dates and times:
WEEKENDS: _____ Every _____ Every Other _____ Other {specify} _____________
From____________________________ to _________________________________
WEEKDAYS: {Specify days} ______________________________________________
From _____________________________ to _______________________________
OTHER: {Specify} _____________________________________________________
___________________________________________________________________
___________________________________________________________________.

The child(ren) shall spend time with the Father on the following dates and times:
WEEKENDS: _____ Every _____ Every Other _____ Other {specify}______________
From____________________________ to _________________________________
WEEKDAYS: {Specify days} ______________________________________________

Florida Supreme Court Approved Family Law Form 12.995(a), Parenting Plan (03/15)
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From _____________________________ to _______________________________
OTHER: {Specify} _____________________________________________________
___________________________________________________________________
___________________________________________________________________.

Please indicate if there is a different time sharing schedule for any child. Complete a
separate Attachment for each child for whom there is a different time sharing schedule.

_____ There is a different time-sharing schedule for the following child(ren) in
Attachment _________.

_____________________________, and _________________________.
(Name of Child) (Name of Child)

2. Holiday Schedule {Choose only one}

a. _____No holiday time sharing shall apply. The regular time-sharing schedule set forth
above shall apply.

b. _____Holiday time-sharing shall be as the parties agree.

c. _____Holiday time-sharing shall be in accordance with the following schedule. The
Holiday schedule will take priority over the regular weekday, weekend, and summer
schedules. Fill in the blanks with Mother or Father to indicate where the child(ren) will
be for the holidays. Provide the beginning and ending times. If a holiday is not specified
as even, odd, or every year with one parent, then the child(ren) will remain with the
parent in accordance with the regular schedule

Holidays Even Years Odd Years Every Year Begin/End Time
Mother’s Day __________ _________ __________ _____________
Father’s Day __________ _________ __________ _____________
President’s Day __________ _________ __________ _____________
M. L. King Day __________ _________ __________ _____________
Easter __________ _________ __________ _____________
Passover __________ _________ __________ _____________
Memorial Day Wkd _______ __________ __________ _____________
4th of July __________ _________ __________ _____________
Labor Day Wkd __________ _________ __________ _____________
Columbus Day Wkd _______ _________ __________ _____________
Halloween __________ _________ __________ _____________
Thanksgiving __________ _________ __________ _____________
Veteran’s Day __________ _________ __________ _____________
Hanukkah __________ _________ __________ _____________
Yom Kippur __________ _________ __________ _____________

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Rosh Hashanah __________ _________ __________ _____________
Child(ren)’s
Birthdays: __________ _________ __________ _____________
__________ __________ _________ __________ _____________
__________ __________ _________ __________ _____________

This holiday schedule may affect the regular Time-Sharing Schedule. Parents may wish to
specify either or both of the following options:

d._____When the parents are using an alternating weekend plan and the holiday
schedule would result in one parent having the child(ren) for three weekends in a row,
the parents will exchange the following weekend, so that each has two weekends in a
row before the regular alternating weekend pattern resumes.

e._____If a parent has the child(ren) on a weekend immediately before or after an
unspecified holiday or non-school day, they shall have the child(ren) for the holiday or
non-school day.

3. Winter Break {Choose only one}

a. _____The _____ Mother _____ Father shall have the child(ren) from the day and time
school is dismissed until December ____________ at ______ a.m./p. m in ____odd-
numbered years _____ even-numbered years ____ every year. The other parent will
have the children for the second portion of the Winter Break. The parties shall alternate
the arrangement each year.

b._____The _____ Mother _____ Father shall have the child(ren) for the entire Winter
Break during _____ odd-numbered years _____ even-numbered years _____ every year.

c._____Other: ___________________________________________________________
_______________________________________________________________________
_______________________________________________________________________.

d. _____Specific Winter Holidays
If not addressed above, the specific Winter Holidays such as Christmas, New Year’s Eve,
Hanukkah, Kwanzaa, etc. shall be shared as follows:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________.

7. Spring Break {Choose only one}

a._____The parents shall follow the regular schedule.

Florida Supreme Court Approved Family Law Form 12.995(a), Parenting Plan (03/15)
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b._____The parents shall alternate the entire Spring Break with the Mother having the
child(ren) during the _____odd-numbered years _____even numbered years.

c._____The _____ Father _____ Mother shall have the child(ren) for the entire Spring
Break every year.

d._____The Spring Break will be evenly divided. The first half of the Spring Break will go
to the parent whose regularly scheduled weekend falls on the first half and the second
half going to the parent whose weekend falls during the second half.

e._____Other: {Specify}_______________________________________.

8. Summer Break {Choose only one}

a._____The parents shall follow the regular schedule through the summer.

b._____The _____ Mother _____ Father shall have the entire Summer Break from
__________after school is out until _______________ before school starts.

c._____The parents shall equally divide the Summer Break as follows: During _____
odd-numbered years_____ even numbered years, the _____ Mother _____ Father shall
have the children from ________ _after school is out until _____________. The other
parent shall have the child(ren) for the second one-half of the Summer Break. The
parents shall alternate the first and second one-halves each year unless otherwise
agreed. During the extended periods of time-sharing, the other parent shall have the
child(ren) ____________________________________________________________.

d._____Other: {Specify}____________________________________________________
_______________________________________________________________________.

6. Number of Overnights:
Based upon the time-sharing schedule, the Mother has a total of _____ overnights
per year and the Father has a total of _____ overnights per year.
Note: The two numbers must equal 365.

7. _____If not set forth above, the parties shall have time-sharing in accordance with the
schedule which is attached and incorporated herein.

VIII. TRANSPORTATION AND EXCHANGE OF CHILD(REN)

6. Transportation {Choose only one}

a.____The ____ Mother ____ Father shall provide all transportation.

Florida Supreme Court Approved Family Law Form 12.995(a), Parenting Plan (03/15)
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b. _____The parent beginning their time-sharing shall provide transportation for the
child(ren).

c._____The parent ending their time-sharing shall provide transportation for the
child(ren).

d._____Other: {Specify}___________________________________________________.

2. Exchange

Both parents shall have the child(ren) ready on time with sufficient clothing packed
and ready at the agreed upon time of exchange. If a parent is more than ______
minutes late without contacting the other parent to make other arrangements, the
parent with the child(ren) may proceed with other plans and activities.
{Choose only one}:

a._____Exchanges shall be at Mother’s and Father’s homes unless both parents agree to
a different meeting place.

b._____Exchanges shall occur at __________________________________________
____________________________________________________________ unless both
parties agree in advance to a different meeting place.

c._____Other: _______________________________________________________.

3. Transportation Costs {Choose only one}

a._____Transportation costs are included in the Child Support Worksheets and/or the
Order for Child Support and should not be included here.

b._____The Mother shall pay ______% and the Father shall pay ______ % of the
transportation costs.

c._____Other: ___________________________________________________________.

4. Foreign and Out-Of-State Travel {Indicate all that apply}

a._____Either parent may travel within the United States with the child(ren) during
his/her time-sharing. The parent traveling with the child(ren) shall give the other parent
at least ____ days written notice before traveling out of state unless there is an
emergency, and shall provide the other parent with a detailed itinerary, including

Florida Supreme Court Approved Family Law Form 12.995(a), Parenting Plan (03/15)
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locations and telephone numbers where the child(ren) and parent can be reached at
least ____ days before traveling.

b._____Either parent may travel out of the country with the child(ren) during his/her
time-sharing. At least ___ days prior to traveling, the parent shall provide a detailed
itinerary, including locations, and telephone numbers where the child(ren) and parent
may be reached during the trip. Each parent agrees to provide whatever
documentation is necessary for the other parent to take the child(ren) out of the
country.

c._____If a parent wishes to travel out of the country with the child(ren), he/she shall
provide the following security for the return of the child
_____________________________________________________________________
_____________________________________________________________________.

d._____Other _________________________________________________________.

IX. EDUCATION

1. School designation.
For purposes of school boundary determination and registration, the _____ Mother’s
_____ Father’s address shall be designated.

2. _____ {If Applicable} The following provisions are made regarding private or home
schooling: ___________________________________________________________
_____________________________________________________________________
_____________________________________________________________________.

3. Other. ________________________________________________________________
____________________________________________________________________
____________________________________________________________________.

X. DESIGNATION FOR OTHER LEGAL PURPOSES

The child(ren) named in this Parenting Plan are scheduled to reside the majority of the time with
the _____ Mother _____ Father. This majority designation is SOLELY for purposes of all other
state and federal laws which require such a designation. This designation does not affect either
parent’s rights and responsibilities under this Parenting Plan.

XI. COMMUNICATION

1. Between Parents

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All communications regarding the child(ren) shall be between the parents. The parents
shall not use the child(ren) as messengers to convey information, ask questions, or set
up schedule changes.

The parents shall communicate with each other: {Indicate all that apply}

_____in person
_____by telephone
_____by letter
_____by e-mail
_____Other: {Specify}_________________________________________.

2. Between Parent and Child(ren)

Both parents shall keep contact information current. Telephone or other electronic
communication between the child(ren) and the other parent shall not be monitored by or
interrupted by the other parent. “Electronic communication” includes telephones,
electronic mail or e-mail, webcams, video-conferencing equipment and software or other
wired or wireless technologies or other means of communication to supplement face to face
contact.

The child(ren) may have _____ telephone _____ e-mail _____ other electronic
communication in the form of _______________________________ with the other parent:
{Choose only one}
a._____Anytime
b._____Every day during the hours of ______________ to ______________________.
c._____On the following days_____________________________________________
during the hours of __________________________ to _________________________.
d._____Other: _________________________________________________________.

3. Costs of Electronic Communication shall be addressed as follows:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________.

XII. CHILD CARE {Choose only one}

a._____Each parent may select appropriate child care providers
b._____All child care providers must be agreed upon by both parents.
c._____Each parent must offer the other parent the opportunity to care for the
child(ren) before using a child care provider for any period exceeding _______ hours.
d._____Other: {Specify}__________________________________________________.

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XIII. CHANGES OR MODIFICATIONS OF THE PARENTING PLAN

Temporary changes to this Parenting Plan may be made informally without a written document;
however, if the parties dispute the change, the Parenting Plan shall remain in effect until further
order of the court.

Any substantial changes to the Parenting Plan must be sought through the filing of a
supplemental petition for modification.

XIV. RELOCATION

Any relocation of the child(ren) is subject to and must be sought in compliance with section
61.13001, Florida Statutes.

XV. DISPUTES OR CONFLICT RESOLUTION

Parents shall attempt to cooperatively resolve any disputes which may arise over the terms of
the Parenting Plan. The parents may wish to use mediation or other dispute resolution methods
and assistance, such as Parenting Coordinators and Parenting Counselors, before filing a court
action.

XVI. OTHER PROVISIONS
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________.

SIGNATURE OF PARENTS

I certify that I have been open and honest in entering into this Parenting Plan. I am satisfied with this
Plan and intend to be bound by it.

Dated: ________________________________
Signature of Mother
Printed Name: ___________________________
Address:
City, State, Zip:
Telephone Number:
Fax Number:

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Designated E-mail Address(es):______________
_______________________________________

STATE OF FLORIDA
COUNTY OF _________________________

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

{Print, type, or stamp commissioned name of
notary or clerk.}
__ Personally known
__ Produced identification
Type of identification produced _____________________________

I certify that I have been open and honest in entering into this Parenting Plan. I am satisfied with this
Plan and intend to be bound by it.

Dated:________________________ _________________________________
Signature of Father
Printed Name: ___________________________
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es):____________
_______________________________________

STATE OF FLORIDA
COUNTY OF _________________________

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

Florida Supreme Court Approved Family Law Form 12.995(a), Parenting Plan (03/15)
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{Print, type, or stamp commissioned name of
notary or clerk.}
__ Personally known
__Produced identification
Type of identification produced ____________________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Mother ( ) Father
This form was completed with the assistance of:
{name of individual} ______________________________________________________________,
{name of business} ________________________________________________________________,
{address} __________________________________________________________________________,
{city} _________________,{state} _, {zip code} _________, {telephone number} ______________.

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INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.995(b),
SUPERVISED/SAFETY-FOCUSED PARENTING PLAN (03/15)

When should this form be used?

A Parenting Plan is required in all cases involving minor child(ren). This form or a similar form should be
used in cases when you feel your child(ren) cannot be safely alone with the other parent or if you
believe shared parental responsibility presents a detriment to the child(ren). In this case, a Parenting
Plan must be developed that allows time-sharing with any minor child(ren), while providing protection
for the child(ren). If safety or supervised time-sharing is not a concern, Parenting Plan, Florida Supreme
Court Approved Family Law Form 12.995(a) or a similar form should be used. If the case involves
relocation, pursuant to Section 61.13001, Florida Statutes, then Relocation/Long Distance Parenting
Plan, Florida Supreme Court Approved Family Law Form 12.995(c) or a similar form should be used.

This form should be typed or printed in black ink. If an agreement has been reached, both parties must
sign the Parenting Plan and have their signatures witnessed by a notary public or deputy clerk. After
completing this form, you should file the original with the clerk of the circuit court in the county where
the petition was filed and keep a copy for your records. You should then refer to the instructions for
your petition, answer, or answer and counterpetition concerning the procedures for setting a hearing or
trial (final hearing). If the parents have not reached an agreement, a proposed Parenting Plan may be
filed by either parent at the time of or any time prior to the final hearing. If an agreed Parenting Plan is
not filed by the parties, the court shall establish a Plan.

IMPORTANT INFORMATION REGARDING E-FILING

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Instructions for Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan
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SELF-REPRESENTED LITIGANTS MAY SERVE DOCUMENTS BY E-MAIL; HOWEVER, THEY ARE NOT
REQUIRED TO DO SO. If a self-represented litigant elects to serve and receive documents by e-mail, the
procedures must always be followed once the initial election is made.

Where can I look for more information?

Special notes...

If you fear that disclosing your address would put you in danger, you should complete a Request for
Confidential Filing of Address, Florida Supreme Court Approved Form 12.980(h), file it with the clerk of
the circuit court and write confidential in the space provided in the Parenting Plan.

At a minimum, the Parenting Plan must describe in adequate detail:
 How the parties will share and be responsible for the daily tasks associated with the upbringing of the
child(ren),
 The time-sharing schedule arrangements that specify the time that the minor child(ren) will
spend with each parent,
 A designation of who will be responsible for any and all forms of health care, school-related
matters, including the address to be used for school-boundary determination and registration, other
activities, and
 The methods and technologies that the parents will use to communicate with the child(ren).

Instructions for Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan
(03/15)
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particular minor child(ren) and the circumstances of that family, as listed in section 61.13(3), Florida
Statutes, including, but not limited to:
 The demonstrated capacity and disposition of each parent to facilitate and encourage a close
and continuing parent-child relationship, to honor the time-sharing schedule, and to be reasonable
when changes are required;
 The anticipated division of parental responsibilities after the litigation, including the extent to
which parental responsibilities will be delegated to third parties;
 The demonstrated capacity and disposition of each parent to determine, consider, and act upon
the needs of the child(ren) as opposed to the needs or desires of the parent;
 The length of time the child(ren) has lived in a stable, satisfactory environment and the
desirability of maintaining continuity;
 The geographic viability of the parenting plan, with special attention paid to the needs of school-
age children and the amount of time to be spent traveling to effectuate the parenting plan. This factor
does not create a presumption for or against relocation of either parent with a child(ren);
 The moral fitness of the parents;
 The mental and physical health of the parents;
 The home, school, and community record of the child(ren);
 The reasonable preference of the child(ren), if the court deems the child(ren) to be of sufficient
intelligence, understanding, and experience to express a preference;
 The demonstrated knowledge, capacity, and disposition of each parent to be informed of the
circumstances of the minor child(ren), including, but not limited to, the child(ren)’s friends, teachers,
medical care providers, daily activities, and favorite things;
 The demonstrated capacity and disposition of each parent to provide a consistent routine for
the child(ren), such as discipline, and daily schedules for homework, meals, and bedtime;
 The demonstrated capacity of each parent to communicate with and keep the other parent
informed of issues and activities regarding the minor child(ren), and the willingness of each parent to
adopt a unified front on all major issues when dealing with the child(ren);
 Evidence of domestic violence, sexual violence, child abuse, child abandonment, or child
neglect, regardless of whether a prior or pending action relating to those issues has been brought. If the
court accepts evidence of prior or pending actions regarding domestic violence, sexual violence, child
abuse, child abandonment, or child neglect, the court must specifically acknowledge, in writing that such
evidence was considered when evaluating the bests interests of the child(ren);
 Evidence that either parent has knowingly provided false information to the court regarding any
prior or pending action regarding domestic violence, sexual violence, child abuse, child abandonment, or
child neglect;
 The particular parenting tasks customarily performed by each parent and the division or
parental responsibilities before the institution of litigation and during the pending litigation, including
the extent to which parenting responsibilities were undertaken by third parties;
 The demonstrated capacity and disposition of each parent to participate and be involved in the
child(ren)’s school and extracurricular activities;
 The demonstrated capacity and disposition of each parent to maintain an environment for the
child(ren) which is free from substance abuse;

Instructions for Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan
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 The capacity and disposition of each parent to protect the child(ren) from the ongoing litigation
as demonstrated by not discussing the litigation with the child(ren), not sharing documents or electronic
media related to the litigation with the child(ren), and refraining from disparaging comments about the
other parent to the child)ren); and
 The developmental stages and needs of the child(ren) and the demonstrated capacity and
disposition of each parent to meet the child(ren)’s developmental needs.

This standard form does not include every possible issue that may be relevant to the facts of your case.
The Parenting Plan should be as detailed as possible to address the time-sharing schedule. Additional
provisions should be added to address all of the relevant factors. The parties should give special
consideration to the age and needs of each child.

In developing the Parenting Plan, you may wish to consult or review other materials which are available
at your local library, law library or through national and state family organizations.

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan
(03/15)
- 886 -
IN THE CIRCUIT COURT OF THE _____________________ JUDICIAL CIRCUIT
IN AND FOR _________________ COUNTY, FLORIDA

Case No: _____________________
Division: _____________________

_______________________________
Mother,
and
_______________________________
Father.

SUPERVISED/SAFETY-FOCUSED PARENTING PLAN

This parenting plan is: {Choose only one}
_____ A Parenting Plan submitted to the court with the agreement of the parties.
_____ A proposed Parenting Plan submitted by or on behalf of:
{Parent’s Name}_________________________________________.
_____ A Parenting Plan established by the court.

This parenting plan is: {Choose only one}
_____ A final Parenting Plan established by the court.
_____ A temporary Parenting Plan established by the court.
_____ A modification of a prior final Parenting Plan or prior final order.

I. PARENTS
Mother
Name:__________________________________________________________________
Address:________________________________________________________________
Telephone Number:_______________________________________________________
E-Mail:_________________________________________________________________
_____ Address Unknown: {Please indicate if mother’s address is unknown}
_____ Address Confidential: {Please indicate if mother’s address and phone numbers are
confidential pursuant to either a _____ Final Judgment for Protection Against Domestic Violence
or other court order ____________________________________________________________.}

Father
Name:__________________________________________________________________
Address:________________________________________________________________
Telephone Number: _______________________________________________________
E-Mail: _________________________________________________________________
_____ Address Unknown: (Please indicate if father’s address is unknown}
_____ Address Confidential: (Please indicate if father’s address and telephone numbers are

Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan (03/15)
- 887 -
confidential pursuant to either a _____ Final Judgment for Protection Against Domestic Violence
or _____other court order ____________________________________________________.)

II. CHILDREN: This parenting plan is for the following child(ren) born to, or adopted by the parties:
(add additional lines as needed)
Name Date of Birth
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

III. JURISDICTION

The United States is the country of habitual residence of the child(ren).

The State of Florida is the child(ren)’s home state for the purposes of the Uniform Child Custody
Jurisdiction and Enforcement Act.

This Parenting Plan is a child custody determination for the purposes of the Uniform Child
Custody Jurisdiction and Enforcement Act, the International Child Abduction Remedies Act, 42
U.S.C. Section 11601 et seq., the Parental Kidnapping Prevention Act, and the Convention on the
Civil Aspects of International Child Abduction enacted at the Hague on October 25, 1980, and for
other state and federal laws.

Other: _________________________________________________________________.

IV. PARENTAL RESPONSIBILITY {Choose only one}

_____ Sole Parental Responsibility
It is in the best interests of the child(ren) that the_____ Mother _____ Father shall have
sole authority to make major decisions for the child(ren.) It is detrimental to the
child(ren) for the parents to have shared parental responsibility.

_____ Shared Parental Responsibility with Decision Making Authority
It is in the best interests of the child(ren) that the parents confer and attempt to agree
on the major decisions involving the child(ren). If the parents are unable to agree, the
authority for making major decisions regarding the child(ren) shall be as follows:

Education/Academic decisions _____ Mother _____ Father
Non-emergency health care _____ Mother _____ Father
___________________________ _____ Mother _____ Father
___________________________ _____ Mother _____ Father

Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan (03/15)
- 888 -
___________________________ _____ Mother _____ Father

_____Other: (Explain) __________________________________________________.

V. TIME SHARING SCHEDULE {Choose only one}

____ No Time-Sharing: The _____ Mother _____Father shall have no contact with
the child(ren) until further order of the court. All parenting decisions shall be made by
the other parent.

1. _____ Supervised Time-Sharing: Whenever the child(ren) are with the _____ Mother
_____ Father, the supervisor shall be present. The _____ Mother _____ Father has the
right to spend time with the child(ren) even though the other parent will be making
most, if not all, of the parenting decisions which are made on the child(ren)’s behalf.
The time-sharing schedule shall be mutually agreed to between the parents, but not less
than the schedule set forth below: {Choose only one}

_____ hours per week. The place(s), and time(s) shall be set by the _____ Mother
_____Father.

_____ From ____ __m. to ____ __ m., on the following day(s)
_____________________
_______________________________________________________________________.

2. _____ Restricted Time-Sharing: The _____ Mother _____ Father shall have time-
sharing with the following restrictions. {The restrictions should be described in detail
such as time-sharing only in public places, no overnight visits, etc.} The time-sharing
schedule shall be mutually agreed upon between the parents, but not less than the
schedule set forth below:___________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________.

3. _______ hours per week. The place(s), and time(s) shall be set by the
_____ Mother _____ Father.

4. ______Other: ___________________________________________________________.

VI. SUPERVISOR AND SUPERVISION {Choose only one}

1. Supervisor. The person supervising the time-sharing shall: {Choose only one}
_____ Be selected by the _____ Mother _____ Father.

Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan (03/15)
- 889 -
_____ Be selected by the _____ Mother _____ Father, subject to the other parent’s approval.

_____ Other: ________________________________________________________________.

2. Restrictions or Level of Supervision: ____________________________________________
___________________________________________________________________________
__________________________________________________________________________ .

3. Costs of Supervision
_____The costs of the supervision shall be paid by the _____ Mother _____ Father

_____Other: ______________________________________________________.

VII. LOCATION: {Choose only one}

The _____ Mother _____ Father shall spend his/her time-sharing with the child(ren) at the
following location(s):

1. _____Supervised visitation center (name and address of facility) ________________________
_______________________________________________________________________.

2._____ _______________________________________ (location) or other location designated
by the _____ Mother _____ Father

3._____Any location designated by the _____ Mother _____ Father with the approval of the
supervisor.

4._____Other: _____________________________________________________ .

VIII. DESIGNATION FOR OTHER LEGAL PURPOSES

1. The child(ren) named in this Safety-Focused Parenting Plan are scheduled to reside the
majority of the time with the _____ Mother _____Father. This majority designation is SOLELY
for purposes of all other state and federal statutes which require such a designation. This
designation does not affect either parent’s rights and responsibilities under this parenting
plan.

2. For purposes of school boundary determination and registration, the _____ Mother’s
_____ Father’s address shall be designated.

Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan (03/15)
- 890 -
IX. TRANSPORTATION AND EXCHANGE OF CHILD(REN)

1. Transportation
The child(ren) shall not be driven in a car unless the driver has a valid driver’s license,
automobile insurance, seat belts, and child safety seats as required by Florida law.

The _____ Mother _____ Father or mutually agreed upon person shall be responsible for
transporting the child(ren) to the exchange point. The child(ren) shall be picked up and/or
returned to the exchange point by {Choose only one}

_____ The _____ Mother _____ Father with the supervisor present.

_____ The supervisor alone.

____ Other: _______________________________________________.

2. Exchange

The exchange of the child(ren) shall occur at: {Indicate all that apply}

a._____ The site of the supervised visit.

b._____ A monitored exchange location {specify name and address of facility}________
________________________________________________________________.

c._____ Other: _________________________________________________.

d._____ The _____ Mother _____ Father is prohibited from coming to the exchange
point.

X. COMMUNICATION

1. Between Parents
All communications regarding the child(ren) shall be between the parents. The
parents shall not use the child(ren) as messengers to convey information, ask questions, or
set up schedule changes.

_____The parents shall communicate with each other: {Indicate all that apply}
_____in person
_____by telephone
_____by letter
_____by e-mail
_____Other: {Specify] ___________________________________________.

Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan (03/15)
- 891 -
_____ No Communication. Unless otherwise prohibited by court order, all information
and communication regarding the child(ren) shall be exchanged via or through
______________________________________________________________________.

2. Between Parent and Child(ren)
The _____ Mother _____ Father {Indicate all that apply}

a._____Shall not telephone, write, or e-mail the child(ren) unless the contact is agreed
to in advance by the other parent.

b._____May write or e-mail the child(ren) at any time. Each parent shall provide a
contact address (and e-mail address if appropriate) to the other parent, unless other
prohibited by court order.

c._____May call the child(ren) on the telephone _____ times per week. The call shall
last no more than _____ minutes and shall take place between _____ __m. and _____
__ m. Each parent shall provide a telephone number to the other parent, unless
otherwise prohibited by court order or law.

d._____ Long distance telephone calls made by the child(ren) to a parent shall be paid
by ______________________. Each parent shall provide a telephone number to the
other parent, unless otherwise prohibited by court order or law.

e._____Other: ___________________________________________________________.

3. Costs of Electronic Communication

“Electronic communication” includes telephones, electronic mail or e-mail, webcams, video-
conferencing equipment and software or other wired or wireless technologies or other
means of communication to supplement face-to face contact.

The costs of electronic communication shall be addressed as follows:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________.

XI. ACCESS TO ACTIVITIES AND EVENTS

The _____ Mother _____ Father {Choose only one}

Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan (03/15)
- 892 -
1._____Shall not attend the child(ren)’s activities and events, including but not limited
to, school, athletic, and extra-curricular activities and events.

2._____May attend the child(ren)’s school, athletic, and extra-curricular activities and
events.

3._____The _____ Mother _____ Father must stay _____ feet from the other parent
and _____ feet from the child.

4._____ Other _______________________________________________.

XII. CHILD(REN)’S SAFETY

The _____ Mother _____ Father shall follow the safety rules checked below.
(Indicate all that apply)

1._____There shall be no firearms in the home, car, or in the child(ren)’s presence
during time-sharing.

2. _____No alcoholic beverages shall be consumed from twenty-four (24) hours before
the child(ren) arrive until they are returned to the other parent.

3._____The child(ren) shall not be disciplined by corporal punishment.

4._____The following person(s) present a danger to the child(ren) and shall not be
present during time-sharing: ________________________________________________
_______________________________________________________________________.

5._____Other: ___________________________________________________________.

XIII. CHANGES OR MODIFICATIONS OF THE PARENTING PLAN

All changes to the Safety-Focused Parenting Plan must be pursuant to a court order.

XIV. OTHER PROVISIONS
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________.

Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan (03/15)
- 893 -
SIGNATURES OF PARENTS

I certify that I have been open and honest in entering into this Parenting Plan. I am satisfied with this
Plan and intend to be bound by it.

Dated: _____________________________________________
Signature of Mother
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es):___________________
__________________________________________
STATE OF FLORIDA
COUNTY OF ___________________________

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

{Print, type, or stamp commissioned name of notary or
clerk}
__ Personally known

__ Produced identification
Type of identification produced _________________________________

Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan (03/15)
- 894 -
I certify that I have been open and honest in entering into this Parenting Plan. I am satisfied with this
Plan and intend to be bound by it.

Dated: ________________________ _____________________________________________
Signature of Father
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
Designated E-mail Address(es):___________________
__________________________________________

STATE OF FLORIDA
COUNTY OF ________________________

Sworn to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

{Print, type, or stamp commissioned name of notary or
clerk.}
__ Personally known
__ Produced identification
Type of identification produced __________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:
[fill in all blanks] This form was prepared for the: {choose only one} ( ) Mother ( ) Father.
This form was completed with the assistance of:
{name of individual} __________________________________________________________,
{name of business} ____________________________________________________________,
{address} ____________________________________________________________________,
{city} ___ ,{state} , {zip code}____________,{telephone number} .

Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan (03/15)
- 895 -
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.995(c)
RELOCATION/LONG DISTANCE PARENTING PLAN (03/15)

When should this form be used?

A Parenting Plan is required in all cases involving time-sharing with minor child(ren), even when time-
sharing is not in dispute. The Parenting Plan must be developed and agreed to by the parents and every
other person entitled to access or time-sharing with the child(ren) and approved by the court. “Other
Person” means an individual who is not the parent, but with whom the child resides pursuant to court
order, or who has the right of access to, time-sharing with or visitation with the child(ren). If the parties
cannot agree to a Parenting Plan or if the parents agreed to a Plan that is not approved by the court, a
Parenting Plan will be established by the court with or without the use of Parenting Plan
Recommendations.

This form or a similar form should be used in the development of a Parenting Plan when you are
planning to relocate your or the child(ren)’s principal residence more than 50 miles from the principal
place of residence:

 at the time of the last order either establishing or modifying time-sharing, or
 at the time of filing the pending action to either establish or modify time-sharing

This form should be typed or printed in black ink. If an agreement has been reached, both parties must
sign the Parenting Plan and have their signatures witnessed by a notary public or deputy clerk. After
completing this form, you should file the original with the clerk of the circuit court in the county where
the petition was filed and keep a copy for your records. You should then refer to the instructions for
your petition, answer, or answer and counterpetition concerning the procedures for setting a hearing or
trial (final hearing). If an agreed Parenting Plan is not filed by the parties, the Court shall establish a
Plan.

IMPORTANT INFORMATION REGARDING E-FILING

Instructions for Florida Supreme Court Approved Family Law Form 12.995(c), Relocation/Long Distance Parenting
Plan (03/15)
- 896 -
IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

Where can I look for more information?

Special notes...

At a minimum, the Relocation/Long Distance Parenting Plan must describe in adequate detail:
 How the parties will share and be responsible for the daily tasks associated with the upbringing
of the child(ren),
 The time-sharing schedule that specifies the time that the minor child(ren) will spend with each
parent and every other person entitled to access or time-sharing,
 A designation of who will be responsible for any and all forms of health care, school-related
matters, including the address to be used for school-boundary determination and registration, other
activities,
 The methods and technologies that the parties will use to communicate with the child(ren), and
 Any transportation arrangements related to access or time-sharing.

Instructions for Florida Supreme Court Approved Family Law Form 12.995(c), Relocation/Long Distance Parenting
Plan (03/15)
- 897 -
The best interests of the child(ren) is the primary consideration in the Parenting Plan. In creating the
Parenting Plan, all circumstances between the parties, including the parties’ historic relationship,
domestic violence, and other factors must be taken into consideration. Determination of the best
interests of the child(ren) shall be made by evaluating all of the factors affecting the welfare and interest
of the particular minor child(ren) and the circumstances of the family as listed in section 61.13(3),
Florida Statutes, including, but not limited to:
 The demonstrated capacity and disposition of each party to facilitate and encourage a
close and continuing parent-child relationship, to honor the time-sharing schedule, and
to be reasonable when changes are required;
 The anticipated division of parental responsibilities after the litigation, including the
extent to which parental responsibilities will be delegated to third parties;
 The demonstrated capacity and disposition of each party to determine, consider, and
act upon the needs of the child(ren) as opposed to the needs or desires of the parent;
 The length of time the child(ren) has lived in a stable, satisfactory environment and the
desirability of maintaining continuity;
 The geographic viability of the parenting plan, with special attention paid to the needs
of school-age children and the amount of time to be spent traveling to effectuate the
parenting plan. This factor does not create a presumption for or against relocation of
either party with a child(ren);
 The moral fitness of the parties;
 The mental and physical health of the parties;
 The home, school, and community record of the child(ren);
 The reasonable preference of the child(ren), if the court deems the child(ren) to be of
sufficient intelligence, understanding, and experience to express a preference;
 The demonstrated knowledge, capacity, and disposition of each party to be informed of
the circumstances of the minor child(ren), including, but not limited to, the child(ren)’s
friends, teachers, medical care providers, daily activities, and favorite things;
 The demonstrated capacity and disposition of each party to provide a consistent routine
for the child(ren), such as discipline, and daily schedules for homework, meals, and bedtime;
 The demonstrated capacity of each party to communicate with and keep the other part(y)ies
informed of issues and activities regarding the minor child(ren), and the willingness of
each party to adopt a unified front on all major issues when dealing with the child(ren);
 Evidence of domestic violence, sexual violence, child abuse, child abandonment, or child
neglect, regardless of whether a prior or pending action relating to those issues has
been brought. If the court accepts evidence of prior or pending actions regarding
domestic violence, sexual violence, child abuse, child abandonment, or child neglect, the
court must specifically acknowledge in writing that such evidence was considered when
evaluating the best interests of the child(ren);
 Evidence that any party has knowingly provided false information to the court regarding
any prior or pending action regarding domestic violence, sexual violence, child abuse,
child abandonment, or child neglect;

Instructions for Florida Supreme Court Approved Family Law Form 12.995(c), Relocation/Long Distance Parenting
Plan (03/15)
- 898 -
 The particular parenting tasks customarily performed by each patty and the division of
parental responsibilities before the institution of litigation and during the pending litigation,
including the extent to which parenting responsibilities were undertaken by third parties;
 The demonstrated capacity and disposition of each party to participate and be involved
in the child(ren)’s school and extracurricular activities;
 The demonstrated capacity and disposition of each party to maintain an environment
for the child(ren) which is free from substance abuse;
 The capacity and disposition of each party to protect the child(ren) from the ongoing
litigation as demonstrated by not discussing the litigation with the child(ren), not sharing
documents or electronic media related to the litigation with the child(ren), and
refraining from disparaging comments about any other party to the child)ren); and
 The developmental stages and needs of the child(ren) and the demonstrated capacity
and disposition of each party to meet the child(ren)’s developmental needs.

This standard form does not include every possible issue that may be relevant to the facts of your case.
The Parenting Plan should be as detailed as possible to address the time-sharing schedule. Additional
provisions should be added to address all of the relevant factors. The parties should give special
consideration to the age and needs of each child.

In developing the Parenting Plan, you may wish to consult or review other materials which are available
at your local library, law library or through national and state family organizations.

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out
these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida Family Law Rules
of Procedure Form 12.900 (a), before he or she helps you. A nonlawyer helping you fill out these forms
also must put his or her name, address, and telephone number on the bottom of the last page of every
form he or she helps you complete.

Instructions for Florida Supreme Court Approved Family Law Form 12.995(c), Relocation/Long Distance Parenting
Plan (03/15)
- 899 -
IN THE CIRCUIT COURT OF THE _____________________ JUDICIAL CIRCUIT,
IN AND FOR ______________________________ COUNTY, FLORIDA

Case No: __________________
Division: __________________

_________________________________,
Petitioner,

And

_________________________________,
Respondent.

RELOCATION/LONG-DISTANCE PARENTING PLAN
This parenting plan is: {Choose only one}
_____ A Parenting Plan submitted to the court with the agreement of the parties.
_____ A proposed Parenting Plan submitted by or on behalf of:
{Name of Parent or Other Person}__________________________________.
_____ A Parenting Plan established by the court.

This parenting plan is: {Choose only one}
_____ A final Parenting Plan established by the court.
_____ A temporary Parenting Plan established by the court.
_____ A modification of a prior final Parenting Plan or prior final order.

I. PARTIES
Mother
Name:__________________________________________________________________
Address: ________________________________________________________________
Telephone Number: _______________________________________________________
E-Mail: _________________________________________________________________

Other Person {If Applicable}
Name:___________________________________________________________________
Address:_________________________________________________________________
Telephone Number_________________________________________________________
E-mail:___________________________________________________________________

Florida Supreme Court Approved Family Law Form 12.995(c), Relocation/Long Distance Parenting Plan
(03/15)
- 900 -
II. CHILDREN: This parenting plan is for the following child(ren):
{Add additional lines as needed}
Name(s) Birth Date(s)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

III. JURISDICTION

The United States is the country of habitual residence of the child(ren).

The State of Florida is the child(ren)’s home state for the purposes of the Uniform Child
Custody Jurisdiction and Enforcement Act.

This Parenting Plan is a child custody determination for the purposes of the Uniform Child
Custody Jurisdiction and Enforcement Act, the International Child Abduction Remedies Act, 42
U.S.C. Sections 11601 et seq., the Parental Kidnapping Prevention Act, and the Convention on
the Civil Aspects of International Child Abduction enacted at the Hague on October 25, 1980,
and for all other state and federal laws.

Other: _____________________________________________________________________.

IV. PARENTAL RESPONSIBILITY AND DECISION MAKING

1. Parental Responsibility {Choose only one}

_____ Shared Parental Responsibility.
It is in the best interests of the child(ren) that the parties confer and jointly make
all major decisions affecting the welfare of the child(ren). Major decisions include,
but are not limited to, decisions about the child(ren)’s education, healthcare, and
other responsibilities unique to this family.

_____ Shared Parental Responsibility with Decision Making Authority
It is in the best interests of the child(ren) that the parties confer and attempt to
agree on the major decisions involving the child(ren). If the parties are unable to
agree, the authority for making major decisions regarding the child(ren) shall be
as follows:

Education/Academic decisions ____ Mother ____ Father ____ Other Person
Non-emergency health care ____ Mother ____ Father ____ Other Person
___________________________ _____ Mother ____ Father ____ Other Person
__________________________ ____ Mother ____ Father ____ Other Person

Florida Supreme Court Approved Family Law Form 12.995(c), Relocation/Long Distance Parenting Plan
(03/15)
- 901 -
__________________________ ____ Mother ____ Father ____ Other Person

_____ Sole Parental Responsibility:
It is in the best interests of the child(ren) that the _____ Mother _____ Father
_____ Other Person shall have sole authority to make major decisions for the
child(ren.) It is detrimental to the child(ren) for the parties to share decision
making.

2. Day-to-Day Decisions
Unless otherwise specified in this plan, each party shall make decisions regarding day-to-
day care and control of each child, including the performance of daily tasks, while the
child is with that party. Regardless of the allocation of decision making in the Parenting
Plan, any party may make emergency decisions affecting the health or safety of the
child(ren) when the child is residing with that party. A party who makes an emergency
decision shall share the decision with the other party as soon as reasonably possible.

3. Extracurricular Activities (Indicate all that apply)

i. _____ Any party may register the child(ren) and allow them to participate in the
activity of the child(ren)’s choice.

ii. _____ The parties must mutually agree to all extracurricular activities.

c. _____ The party with the minor child(ren) shall transport the minor child(ren) to
and/or from all mutually agreed upon extra-curricular activities, providing all
necessary uniforms and equipment within the party’s possession.

d. _____ The costs of the extracurricular activities shall be paid by:
Mother _______% Father ________ %

e. _____ The uniforms and equipment required for the extracurricular activities
shall be paid by:
Mother _______ % Father _________%

f. _____ Other: _____________________________________________________ .

V. INFORMATION SHARING. Unless Otherwise Indicated or Ordered by the Court:

1. Unless otherwise prohibited by law, the parties shall have access to medical and school
records, and information pertaining to the child(ren), and shall be permitted to
independently consult with any and all professionals involved with the child(ren). The
parties shall cooperate with each other in sharing information related to the health,
education, and welfare of the child(ren) and they shall sign any necessary documentation
ensuring that all parties have access to said records.

2. Each party shall be responsible for obtaining records and reports directly from the
school and health care providers.

Florida Supreme Court Approved Family Law Form 12.995(c), Relocation/Long Distance Parenting Plan
(03/15)
- 902 -
3. The parties have equal rights to inspect and receive governmental agency and law
enforcement records concerning the child(ren).

4. The parties shall have equal and independent authority to confer with the child(ren)’s
school, day care, health care providers, and other programs with regard to the
child(ren)’s educational, emotional, and social progress.

5. The parties shall be listed as “emergency contacts” for the child(ren).

6. Each party has a continuing responsibility to provide a residential and mailing address,
and contact telephone number (s) to the other parties. Each party shall notify the other
parties in writing within 24 hours of any changes. Each party shall notify the court in
writing within seven (7) days of any changes.

7. Other: _________________________________________________________________
_______________________________________________________________________.

VI. SCHEDULING

1. School Calendar
a. If necessary, on or before ______________ of each year, the parties should
obtain a copy of the school calendar for the next school year. The parties shall
discuss the calendars and the time-sharing schedule so that any differences or
questions can be resolved.

b. The parties shall follow the school calendar of: {Indicate all that apply}
_____ the oldest child
_____ the youngest child
_____ ______________ County
_____ _________________ School

3. Schedule Changes {Indicate all that apply}

1. _____ A party making a request for a schedule change will make the request as
soon as possible, but in any event, except in cases of emergency, no less than
_____________________________________ before the change is to occur.

2. _____ A party requesting a change of schedule shall be responsible for any
additional child care, or transportation costs caused by the change.

3. _____ Other ______________________________________________________.

Florida Supreme Court Approved Family Law Form 12.995(c), Relocation/Long Distance Parenting Plan
(03/15)
- 903 -
VII. TIME-SHARING SCHEDULE

1. Weekday and Weekend Schedule
The following schedule shall apply beginning on ________________________ with the
_____ Mother _____ Father _____ {If Applicable} Other Person and continue as follows:

The child(ren) shall spend time with the Mother on the following dates and times:
WEEKENDS: _____ Every _____ Every Other _____ Other {Specify} :
______________________________________________________________
From ___________________________ to ___________________________
WEEKDAYS: {Specify days} _______________________________________
From _____________________________ to _________________________
OTHER: {Specify} _______________________________________________
______________________________________________________________
______________________________________________________________

The child(ren) shall spend time with the Father on the following dates and times:
WEEKENDS: _____ Every _____ Every Other _____ Other {Specify}:
______________________________________________________________
From____________________________ to ___________________________
WEEKDAYS: {Specify days} ________________________________________
From _____________________________ to __________________________
OTHER: {Specify} _________________________________________________
_______________________________________________________________
_______________________________________________________________

The child(ren) shall spend time with the Other Person {If Applicable} on the following
dates and times:
WEEKENDS: _____ Every _____ Every Other _____ Other {Specify} :
______________________________________________________________
From _____________________________to __________________________
WEEKDAYS: {Specify Days}________________________________________
From _____________________________to __________________________
OTHER: {Specify} ________________________________________________
______________________________________________________________
______________________________________________________________

Please indicate if there is a different time sharing schedule for any child. Complete a
separate Attachment for each child for whom there is a different time sharing schedule.

_____ There is a different time-sharing schedule for the following child(ren) in
Attachment _____.
______________________________, and _________________________.
{Name of Child} {Name of Child}

Florida Supreme Court Approved Family Law Form 12.995(c), Relocation/Long Distance Parenting Plan
(03/15)
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2. Holiday Schedule {Choose only one}

a. _____No holiday time sharing shall apply. The regular time-sharing schedule set forth above
shall apply.

b. _____Holiday time-sharing shall be as the parties agree.

c. _____Holiday time-sharing shall be in accordance with the following schedule. The Holiday
schedule will take priority over the regular weekday, weekend, and summer
schedules. Fill in the blanks with Mother, Father, or
{If Applicable} Other Person to indicate where the child(ren) will be for the
holidays. Provide the beginning and ending times. If a holiday is not specified as
even, odd, or every year with one party, then the child(ren) will remain with the
other party in accordance with the regular schedule

Holidays Even Years Odd Years Every Year Begin/End Time
Mother’s Day ______ ______ ______ ____________
Father’s Day ______ ______ ______ ____________
President’s Day ______ ______ _______ ____________
Martin Luther King Day ______ _______ _______ ____________
Easter ______ _______ _______ ____________
Passover ______ _______ _______ ____________
Memorial Day Weekend ______ _______ _______ ____________
th
4 of July ______ _______ _______ ____________
Labor Day Weekend ______ _______ _______ ____________
Columbus Day Weekend _____ _______ _______ ____________
Halloween ______ ________ _______ ____________
Thanksgiving ______ ________ _______ ____________
Veteran’s Day ______ ________ _______ ____________
Hanukkah ______ ________ _______ ____________
Yom Kippur ______ _________ _______ ____________
Rosh Hashanah ______ _________ _______ _____________
Child(ren)’s Birthdays ______ _________ _______ _____________
_______________ ______ _________ _______ _____________
_______________ ______ _________ _______ ______________

This holiday schedule may affect the regular time-
sharing schedule. Parties may wish to specify
one or more of the following options:

d_____ When the parties are using an alternating weekend plan and the holiday schedule
would result in one party having the child(ren) for three weekends in a row, the
parties will exchange the following weekend, so that each has two weekends in a
row before the regular alternating weekend pattern resumes.

Florida Supreme Court Approved Family Law Form 12.995(c), Relocation/Long Distance Parenting Plan
(03/15)
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e. _____ If a party has the child(ren) on a weekend immediately before or after an
unspecified holiday or non-school day, they shall have the child(ren) for the
holiday or non-school day.

3. Winter Break {choose only one}

a. _____ The _____ Mother _____ Father _____{If Applicable} Other Person shall have the
child(ren) from the day and time school is dismissed until December ____ at ____ a.m./p. m
in _____odd-numbered years _____ even-numbered years _____ every year. The other
party will have the child(ren) for the second portion of the Winter Break. The parties shall
alternate the arrangement each year.

b._____ The _____ Mother _____ Father _____ {If Applicable} Other Person shall have the
child(ren) for the entire Winter Break during _____ odd-numbered years _____ even-
numbered years _____ every year

c._____ Other:_________________________________________________________
______________________________________________________________
______________________________________________________________

4. Specific Winter Holidays
If not addressed above, the specific Winter Holidays such as Christmas, New Year’s Eve,
Hanukkah, Kwanzaa, etc. shall be shared as follows:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________.

5. Spring Break {Choose only one}

a. _____The parties shall follow the regular schedule.

b. _____The parties shall alternate the entire Spring Break with the _____ Mother
_____ Father _____ {If Applicable} Other Person having the child(ren) during
the _____ odd-numbered _____ even-numbered years

c. _____The _____ Father _____ Mother _____ {If Applicable} Other Person shall have the
child(ren) for the entire Spring Break every year.

d. _____The Spring Break will be evenly divided. The first half of the Spring Break will go
to the party whose regularly scheduled weekend falls on the first half and the
second half going to the party whose weekend falls during the second half.

e. _____Other: __________________________________________________________.

Florida Supreme Court Approved Family Law Form 12.995(c), Relocation/Long Distance Parenting Plan
(03/15)
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6. Summer Break {Choose only one}

a. _____ The parents shall follow the regular schedule through the summer.

b. _____ The _____ Mother _____ Father _____ {If Applicable} Other Person shall
have the entire Summer Break from _____________________________after
school is out until ____________________ before school starts.

c. _____ The parties shall equally divide the Summer Break as follows:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

d. _____ Other:
__________________________________________________________
_________________________________________________________________.

7. Number of Overnights:

Based upon the time-sharing schedule, the Mother has a total of _____ overnights per year,
the Father has a total of ____ overnights per year and {If Applicable} the Other Person has a
total of _____ overnights per year. Note: The total of these numbers must equal 365.

8. Attached Time-Sharing Schedule:

_____If not set forth above, the parties shall have time-sharing in accordance with the
schedule which is attached as Attachment ______and incorporated herein.

VIII. TRANSPORTATION AND EXCHANGE OF CHILD(REN)

1. The parties shall have the child(ren) ready on time with sufficient clothing packed
and ready at the agreed upon time of exchange. All necessary information
and medicines will accompany the child(ren).

2. The parties shall exchange travel information and finalize travel plans at least
______days in advance of the date of travel. Except in cases of emergency,
any party requesting a change of travel plans after the date of finalization
shall be solely responsible for any additional costs.

3. Automobile Transportation and Exchange {Choose only one}
If a party is more than _____minutes late without contacting the other party to make
other arrangements, the party with the child(ren) may proceed with other plans and
activities.

Florida Supreme Court Approved Family Law Form 12.995(c), Relocation/Long Distance Parenting Plan
(03/15)
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a._____ The _____ Mother _____Father _____ {If Applicable} Other Person shall
provide all transportation.

b. _____ The _____ Mother _____Father _____ {If Applicable} Other Person shall
pick up the child(ren) at the beginning of the visit and the other party shall pick up the
child(ren) at the end of the visit. The exchange shall take place:
_____ At the parties’ homes unless otherwise agreed
_____ At the following location unless the parties agree in advance to a different
location:{specify}______________________________________________.
_____ The parties shall meet at the following central location:
{specify}_________________________________________________________
________________________________________________________________.

c. _____Other:___________________________________________________________.

4. Airplane and Other Public Transportation and Exchange

Airline regulations govern the age at which a child may fly unescorted. An older child or
children may fly under such regulations as each airline may establish.

a._____ Until a child reaches the age of ______, the parties agree that the
child(ren) shall take a direct flight and/or fly accompanied by:
_____________________.

b._____ Once a child reaches the age of _____, the child shall be permitted to fly
accompanied by an airline employee.

c._____ Once a child reaches the age of _____, the child shall be permitted to fly
unescorted.

d._____ Other:
_______________________________________________________.

Airline reservations should be made well in advance and preferably, non-stop or direct.

All flight information shall be sent to the other party(ies) at least _____days in advance of
the flight by the party purchasing the tickets.

If the child(ren) are flying accompanied by a party, the party picking up the child(ren) shall
exchange the child(ren) with the other party at__________________ and the party
returning the child(ren) shall exchange the children at _________________________.
If the exchange is to be made at the airport, the party flying in to pick up or drop off the
child(ren) from/to the airport must notify the other party of any flight delays.

Florida Supreme Court Approved Family Law Form 12.995(c), Relocation/Long Distance Parenting Plan
(03/15)
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Unless otherwise agreed in advance, the party taking the child(ren) to the airport must call
the other party(ies) immediately upon departure to notify the other party(ies) that the
child(ren) is/are arriving, and the party who meets the child(ren) must immediately notify
the other party(ies) upon the child(ren)’s arrival.

5. Costs of Airline and Other Public Transportation {Indicate all that apply}

a. _____Ticket Purchase {If Applicable}:
The parties shall work together to purchase the most convenient and least
expensive tickets.

After consultation among the parties, it shall be the responsibility of
___________________ to purchase the tickets by {date} _______________.
All parties entitled to access to, or time-sharing with the child(ren) shall be
notified of the purchase by {date}_____________________.

Proof of the purchase and a copy of the itinerary (choose only one) [ ] shall be
provided to all parties by {date}___________________[ ] shall not be provided.

Unless otherwise agreed or in the case of an unavoidable emergency, any costs
incurred by a missed travel connection shall be the sole responsibility of the party
who failed to timely deliver the child(ren) to the missed connection.

b. _____Transportation costs are included in the Child Support Worksheets and/or the
Order for Child Support and should not be included here.

c. _____Mother shall pay _____% Father shall pay _____% of the transportation costs.

d. _____Mother shall pay _____% Father shall pay _____% of the transportation costs for
an adult to accompany the child(ren) during travel.

e. _____If the parties are sharing travel costs, the non-purchasing party shall reimburse
the other party within ______days of receipt of documentation establishing the
travel costs.

f. _____Other:____________________________________________________.

6. Foreign and Out-Of-State Travel {Indicate all that apply}

a. _____ The parties may travel within the United States with the child(ren) during
his/her time-sharing. The party traveling with the child(ren) shall give the other
party(ies) at least ____ days written notice before traveling out of state unless
there is an emergency, and shall provide the other party(ies) with a detailed

Florida Supreme Court Approved Family Law Form 12.995(c), Relocation/Long Distance Parenting Plan
(03/15)
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itinerary, including locations and telephone numbers where the child(ren) and
party can be reached at least ____ days in advance of the date of travel.

b. _____A party may travel out of the country with the child(ren) during his/her time-
sharing. At least ____ days in advance of the date of travel, the party shall
provide a detailed itinerary, including locations, and telephone numbers where
the child(ren) and party may be reached during the trip. Each party agrees to
provide whatever documentation is necessary for the other party(ies) to take the
child(ren) out of the country.

c. _____If a party wishes to travel out of the country with the child(ren), he/she shall
provide the following security for the return of the child ___________________
_________________________________________________________________.

d. _____Other___________________________________________________________.

7. Other Travel and Exchange Arrangements: ___________________________________
_______________________________________________________________________
_______________________________________________________________________

IX. EDUCATION

4. School designation. For purposes of school boundary determination and registration, the
_____ Mother’s _____ Father’s _____ {If Applicable} Other Person’s address shall be
designated.

5. {If Applicable} The following provisions are made regarding private or home schooling:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________.

6. Other. ________________________________________________________________
______________________________________________________________________
______________________________________________________________________.

X. DESIGNATION FOR OTHER LEGAL PURPOSES

The child(ren) named in this Parenting Plan are scheduled to reside the majority of the time
with the _____ Mother _____ Father _____ {If Applicable} Other Person. This majority
designation is SOLELY for purposes of all other state and federal laws which require such a
designation. This designation does not affect the rights or responsibilities of any party under
this Parenting Plan.

XI. COMMUNICATION

4. Between Parties

Florida Supreme Court Approved Family Law Form 12.995(c), Relocation/Long Distance Parenting Plan
(03/15)
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All communications regarding the child(ren) shall be between the parties. The parties
shall not use the child(ren) as messengers to convey information, ask questions, or set up
schedule changes.

The parties shall communicate with each other by: {Indicate all that apply}
_____ in person
_____ by telephone
_____ by letter
_____ by e-mail
_____ Other:___________________________________________________.

5. Between Parties and Child(ren)

The parties shall keep contact information current. Telephone or other electronic
communication between the child(ren) and another party shall not be monitored by or
interrupted by the other party. “Electronic communication” includes telephones,
electronic mail or e-mail, webcams, video-conferencing equipment and software or other
wired or wireless technologies or other means of communication to supplement face to
face contact.

The child(ren) may have _____ telephone _____ e-mail _____ other electronic
communication in the form of ___________________________________ with the other
party: {Choose only one}
_____ Anytime
_____ Every day during the hours of ______________ to ______________________
_____ On the following days_______________________________________
during the hours of _______________________ to _______________________
_____ Other: _________________________________________________________

6. Costs of Electronic Communication shall be addressed as follows:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

XII. CHILD CARE {Choose only one}

1. _____ Each party may select appropriate child care providers
2. _____ All child care providers must be agreed upon by the parties.
3. _____ Each party must offer the other party the opportunity to care for the child(ren)
before using a child care provider for any period
exceeding _______ hours.
4. _____ Other ________________________________________________________.

XIII. CHANGES TO OR MODIFICATIONS OF THE PARENTING PLAN

Florida Supreme Court Approved Family Law Form 12.995(c), Relocation/Long Distance Parenting Plan
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Temporary changes may be made informally without a written document. When the parties
do not agree, this Parenting Plan remains in effect until further order of the court.

Any substantial changes to the Parenting Plan must be sought through the filing of a
supplemental petition for modification.

XIV. RELOCATION

Any relocation of the child(ren) is subject to and must be sought in compliance with Section
61.13001, Florida Statutes.

XV. DISPUTES OR CONFLICT RESOLUTION

The parties shall attempt to cooperatively resolve any disputes which may arise over the
terms of the Parenting Plan. The parties may wish to use mediation or other dispute
resolution methods and assistance, such as Parenting Coordinators and Parenting Counselors,
before filing a court action.

Florida Supreme Court Approved Family Law Form 12.995(c), Relocation/Long Distance Parenting Plan
(03/15)
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SIGNATURES OF PARTIES

I certify that I have been open and honest in entering into this Parenting Plan. I am satisfied with this
plan and intend to be bound by it.

Dated: ______________________ _______________________________________
Signature of Mother

STATE OF FLORIDA
COUNTY OF ____________________

Sworn to or affirmed and signed before me on __________ by ___________________________.

_______________________________________
NOTARY PUBLIC or DEPUTY CLERK

I certify that I have been open and honest in entering into this Parenting Plan. I am satisfied with this
plan and intend to be bound by it.

Florida Supreme Court Approved Family Law Form 12.995(c), Relocation/Long Distance Parenting Plan
(03/15)
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Dated: ______________________ _______________________________________
Signature of Father

STATE OF FLORIDA
COUNTY OF ____________________

Sworn to or affirmed and signed before me on __________ by ___________________________.

_______________________________________
NOTARY PUBLIC or DEPUTY CLERK

_______________________________________
[Print, type, or stamp commissioned name of notary or
deputy clerk.]

____ Personally known
____ Produced identification
____ Type of identification produced ________________________________

I certify that I have been open and honest in entering into this Parenting Plan. I am satisfied with this
plan and intend to be bound by it.

Florida Supreme Court Approved Family Law Form 12.995(c), Relocation/Long Distance Parenting Plan
(03/15)
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Dated: ______________________ _______________________________________
Signature of Other Person

STATE OF FLORIDA
COUNTY OF ____________________

Sworn to or affirmed and signed before me on __________ by ___________________________.

_______________________________________
NOTARY PUBLIC or DEPUTY CLERK

_______________________________________
[Print, type, or stamp commissioned name of notary or
deputy clerk.]

____ Personally known
____ Produced identification
____ Type of identification produced ________________________________

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW: [fill in
all blanks] This form was prepared for the: {choose only one} ( ) Mother ( ) Father ( ) Other Person.
This form was completed with the assistance of:
{name of individual} __________________________________________________________________,
{name of business}_____________________________________________________________________,
{address} ____________________________________________________________________________,
{city} ________________, {state} _____,{zip code}__________,{telephone number} _________________.

Florida Supreme Court Approved Family Law Form 12.995(c), Relocation/Long Distance Parenting Plan
(03/15)
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