Fillable INSTRUCTIONSFORFLORIDASUPREMECOURTAPPROVEDFAMILYLAW FORM12.902(d),UNIFORMCHILDCUSTODYJURISDICTIO NAND ENFORCEMENTACT(UCCJEA)AFFIDAVIT(12/10) (Duval County Clerk of Courts)

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INSTRUCTIONSFORFLORIDASUPREMECOURTAPPROVEDFAMILYLAW FORM12.902(d),UNIFORMCHILDCUSTODYJURISDICTIO NAND ENFORCEMENTACT(UCCJEA)AFFIDAVIT(12/10) (Duval County Clerk of Courts)

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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(12/10)

INSTRUCTIONSFORFLORIDASUPREMECOURTAPPROVEDFAMILYLAW

FORM12.902(d),UNIFORMCHILDCUSTODYJURISDICTIO NAND

ENFORCEMENTACT(UCCJEA)AFFIDAVIT(12/10)



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.



WhatshouldIdonext?



Acopyofthisformmustbemailedorhanddeliveredtotheotherpartyinyourcase,ifitisnotserved

onhimorherwithyourinitialpapers.



 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schedul ewiththeminorchild(ren).Iftheparen

ts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yo

u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pag e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(12/10)

INTHECIRCUITCOURTOFTHEFourthJUDICIALCIRCUIT,

INANDFORDUVALCOUNTY,FLORIDA



CaseNo.: 

Division:FM‐V

,

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duri ngthattimeare:



THEFOLLO

WING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(12/10)



____/____



*Ifyouarethepetitionerinaninjunctionforprotectionagainstdomesticviolencecaseandyouhave

filedaRequest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FOLLO

WINGINFORMATIONISTRUEABOUTCHILD#:



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



____/____



____/____



____/____



____/____



____/____



THEFOLLOWINGINFORMATIONISTRUEABOUTCHILD#:



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(12/10)



____/____



____/____



____/____



____/____



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proceedin

g

pendinginacourtofthisoranotherstateconcerningachildsubjecttothisproceeding,other

thansetoutinitem2.Explain:

a. Nameofeachchild: 

b. Typeofproceeding: 

c. Courtandstate: 

d. 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KN

OWTHATTH

E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: 



FloridaSupremeCourtApprovedFamilyLawForm12.902(d),UniformChildCustodyJurisdictionandEnforcement

Act(UCCJEA)Affidavit(12/10)

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subj ecttoexistingchildsupportorder(s)inthis

oranystateorterritory.

___ 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procee

ding.



Icertifythatacopyofthisdocumentwas[Chooseonlyone]()mailed()faxedandmailed()hand

deliveredtotheperson(s)listedbelowon{date} .



Otherpartyorhis/herattorney:

Name:

Address:

City,State,Zip:_______

FaxNumber:



FloridaSupremeCourtApprovedFamilyLawForm12.902(d),UniformChildCustodyJurisdictionandEnforcement

Act(UCCJEA)Affidavit(12/10)

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: 

STATEOFFLORIDA

COUNTYOFDUVAL



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]

I,{fulllegalnameandtradenameofnonlawyer} ,

anonlawyer,locatedat{street},{city} ,

{state}   , {phone}    , helped{name} ,

whoisthe[Chooseonlyone]petitionerorrespondent,filloutthisform.

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INSTRUCTIONSFORFLORIDASUPREMECOURTAPPROVEDFAMILYLAW FORM12.902(d),UNIFORMCHILDCUSTODYJURISDICTIO NAND ENFORCEMENTACT(UCCJEA)AFFIDAVIT(1210) (Duval County Clerk of Courts)

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Completed 9 January 2021

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