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FORM 12.941(d): INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED (Florida)

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INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.941(d)
EMERGENCY VERIFIED MOTION FOR CHILD PICK-UP ORDER (11/15)
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
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
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.
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.
Instructions for Florida Supreme Court Approved Family Law Form 12.941(d), Emergency Verified Motion
for Child Pick-Up Order (11/15)
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?
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 yourmotion.
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.
OR
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 (11/15)
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
IN THE CIRCUIT COURT OF THE _______________________ JUDICIAL CIRCUIT,
IN AND FOR ________________________ COUNTY, FLORIDA
__________________________________,
Petitioner,
and
__________________________________,
Respondent,
Case No.: ___________________________ ___
Division:
__________________________________________________________________________________ ________
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 possessionof
{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}:
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 madeon {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}
Florida Supreme Court Approved Family Law Form 12.941(d), Emergency Verified Motion for Child Pick-
Up Order (11/15)
_______________________________________________________________________________
_______________________________________________________________________________
________________________________________________________________________________
______________________________________________________________________________
________________________________________________________________________________
______________________________________________________________________________
________________________________________________________________________________
______________________________________________________________________________
________________________________________________________________________________
______________________________________________________________________________
________________________________________________________________________________
______________________________________________________________________________
________________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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 thebirth 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 thismotion.
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 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}: ________________________________________________
Florida Supreme Court Approved Family Law Form 12.941(d), Emergency Verified Motion for Child Pick-
Up Order (11/15)
________________________________________________________________________________
___________________________________________________________________________
____________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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. !ttorneys’ Fees, Costs, and Suit Monies.
[Indicate if applicable]
_____ I have filed this motion because of wrongful acts of the person listed inparagraph 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
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 (11/15)
_____________________________________________
_____________________________________________
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 (11/15)
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FORM 12.941(d): INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED (Florida)

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Completed 10 January 2021

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