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IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL (Pinellas County Clerk of the Circuit Court and Comptroller)

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(AFFI) approved by court for use June 2016
Template Name: MH BA Affidavit in Support of Petition for Involuntary Exam
IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL CIRCUIT
IN AND FOR PINELLAS COUNTY, FLORIDA
PROBATE DIVISION
IN RE: Reference Number:
Affidavit In Support of Petition Seeking Ex Parte Order Requiring Involuntary
Examination
I, _____________________, SWEAR that the following testimony is given honestly, in good faith,
and to the best of my knowledge. I have seen the following behavior, which causes me to believe that
there is a good chance that the PERSON will cause serious bodily harm to himself/herself or others. On
(date)________________ at approximately (time)___________ am/pm. I saw the PERSON ______________
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(AFFI) approved by court for use June 2016
Template Name: MH BA Affidavit in Support of Petition for Involuntary Exam
Affidavit In Support of Petition (page 2)
Reference Number: ___________________
Other similar behavior I have personally seen is as follows: (include dates/times) _____________________
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I understand that this sworn statement is given under oath and will be treated as though it was made
before a judge in a court of law. I understand that any information in this sworn statement which is not to
the best of my knowledge and done in good faith may expose me to a penalty for perjury and other
possible penalties under the statutes of the State of Florida.
Under penalties of perjury, I declare that I have read the foregoing document and that the facts
stated in it are true.
Signature of Affiant: _______________________________________
SWORN TO AND SUBSCRIBED before me
this ______ day of _______________, _________
By: ______________________ who is personally known to me or presented _____________________
as identification.
____________________________________ Place Clerk Seal or
Deputy Clerk OR Notary Public Signature Notary Stamp here
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IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL (Pinellas County Clerk of the Circuit Court and Comptroller)

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Completed 10 February 2021

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