Fillable FORM 12.902(d): INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED (Pinellas County Clerk of the Circuit Court and Comptroller)

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FORM 12.902(d): INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED (Pinellas County Clerk of the Circuit Court and Comptroller)

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Instructions for Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody
Jurisdiction and Enforcement Act (UCCJEA) Affidavit (11/15)
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.902(d)
UNIFORM CHILD CUSTODY JURISDICTION AND ENFORCEMENT ACT
(UCCJEA) AFFIDAVIT (11/15)
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
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, if it is
not served on him or her with your initial papers.
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. If you elect to participate in electronic service, which means serving or receiving
pleadings by electronic mail (e-mail), or through the Florida Courts E-Filing Portal, you must review
Florida Rule of Judicial Administration 2.516. You may find this rule at www.flcourts.org through the link
to the Rules of Judicial Administration provided under either Family Law Forms: Getting Started, or Rules
of Court in the A-Z Topical Index.
Instructions for Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody
Jurisdiction and Enforcement Act (UCCJEA) Affidavit (11/15)
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 sections 61.501-61.542, Florida Statutes.
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.
Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody Jurisdiction and
Enforcement Act (UCCJEA) Affidavit (11/15)
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
(From/To)
Address (including city and
state) where child lived
Name and present address of
person child lived with
Relationship
to child
/present*
____/____
____/____
Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody Jurisdiction and
Enforcement Act (UCCJEA) Affidavit (11/15)
____/____
____/____
____/____
* 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
(From/To)
Address (including city and
state) where child lived
Name and present address of
person child lived with
Relationship
to child
/present*
____/____
____/____
____/____
____/____
____/____
Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody Jurisdiction and
Enforcement Act (UCCJEA) Affidavit (11/15)
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
(From/To)
Address (including city and
state) where child lived
Name and present address of
person child lived with
Relationship
to child
/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):
Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody Jurisdiction and
Enforcement Act (UCCJEA) Affidavit (11/15)
[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]
____ 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 (11/15)
_____The child(ren) described in this affidavit are subject to the following existing child support
order(s):
Name of each child: ____________________________________________________________________
Type of proceeding: ____________________________________________________________________
Court and address: _____________________________________________________________________
Date of court order/judgment (if any): _____________________________________________________
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):____________________
_____________________________________________
Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody Jurisdiction and
Enforcement Act (UCCJEA) Affidavit (11/15)
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} ________________.
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FORM 12.902(d): INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED (Pinellas County Clerk of the Circuit Court and Comptroller)

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Completed 10 February 2021

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