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PETITION FOR SUPPORT AND PARENTING PLAN UNCONNECTED
WITH DISSOLUTION OF MARRIAGE WITH
DEPENDENT OR MINOR CHILD (REN)
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02/2018
Ken BurKe, C.P.A.
ClerK of the CirCuit Court And ComPtroller
PinellAs County, floridA
www.mypinellasclerk.org
PETITION FOR SUPPORT AND PARENTING PLAN UNCONNECTED
WITH DISSOLUTION OF MARRIAGE WITH
DEPENDENT OR MINOR CHILD (REN)
PETITION FOR SUPPORT AND PARENTING PLAN UNCONNECTEDWITH
DISSOLUTION OF MARRIAGE WITH DEPENDENT OR MINOR CHILD (REN)
FILING FEE: $300.00
SUMMONS ISSUANCE FEE: $10.00 PER SUMMONS
COPIES REQUIRED: Originals to the Clerk.
(1) Set of copies for service.
(1) Set of copies for your records.
ADDITIONAL COSTS:
$3.50 per acknowledgement. (If you do not have your signature notarized in the required
spaces before filing, the Deputy Clerk can do this for you. Please DO NOT SIGN until a Notary
or Deputy Clerk instructs you to do so. )
PROCESS SERVER/SERVICE FEE:
You must contact a private process server, or persons allowed to do service in the county
where services is to be done, to obtain their services fees. You can get a list of local process
servers from the sheriff by accessing a link through our website at www.MyPinellasClerk.org
(You must provide a pre-addressed stamped envelope to mail all of your issued summons
and/or copies for service. If sufficient envelope postage is not provided, your summons will
not be returned or mailed.)
04-2018
SELF HELP CENTER
The Self Help Centers are the result of a collaborative effort between the Clerk’s Office, the Sixth Judicial Circuit,
the Community Law Program and the Clearwater Bar Association.
The purpose of the Clerk's Legal Self Help Centers is to assist citizens representing
themselves in court (sometimes referred to as pro se persons) who do NOT have a private attorney.
Citizens who represent themselves in court and do not already have a private attorney representing them, can
now get affordable legal assistance.
OUR SERVICES INCLUDE:
• Schedule an appointment to consult with an attorney for a minimum of $15.00*
(Attorneys may assist with Family Law, Small Claims and Landlord/Tenant matters ONLY.)
• Purchase forms and packets for the civil court actions listes above
• Have documents notarized
• Make copies
Open Monday through Friday from 8:30 a.m. until 4:30 p.m.:
•
The Clearwater Self Help Center
The New Courthouse
315 Court Street, Room 114
Clearwater, FL 33756
Phone: (727) 464-5150
Fax: (727) 453-3423
o Appointments may be scheduled for Wednesday,
Thursday and/or Friday.
o A Spanish interpreter provided by the
Hispanic Outreach Center is available by
appointment at the Clearwater location
•
The St. Petersburg Self Help
Center
The St. Petersburg Judicial Building
545 First Avenue North, Room 103
St Petersburg, FL 33701
Phone: (727) 582-7941
Fax: (727) 582-7945
o Appointments may be scheduled for
Monday, Wednesday, and/or Friday.
• The North County Branch Self Help Center
29582 U.S. 19 North
Clearwater, FL 33761
Phone: (727) 464-5150
Fax: (727) 453-3423
o Attorney appointments may be scheduled
for Tuesday only at this office.
Self Help Center Now Offering Online Scheduling of attorney consultation appointments for pro se litigants
that do not already have an attorney. To schedule an appointment online using a credit card, please visit
www.mypinellasclerk.org
and click on the SELF HELP CENTER link in the top menu.
*Attorney appointments may only be scheduled for a minimum of 15 minutes to a maximum of one hour. All appointments must be
scheduled in 15-minute increments, i.e., 15, 30, 45 or 60 minutes at a rate of $1 (one dollar) per minute, therefore payments will be $15, $30,
$45 or $60 accordingly.
Attorney consultation fees must be paid when the appointment time is scheduled. Payments must be by credit card,cash check or money
order. Refunds will not be issued for missed appointments.
Ken Burke, CPA
Clerk of the Circuit Court
& Comptroller
Pinellas County, Florida
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Administrative Office of the Courts
The Sixth Judicial Circuit of Florida
(727)582-7200
CASE PROGRESSION CHECKLIST
ORIGINAL PETITIONS (Except Dissolution of Marriage)
This checklist has been prepared to assist you with the necessary procedure for bringing your case to final hearing. This
checklist lists the minimum
requirements and, even though fairly specific, may not be all-inclusive for every case. I
It is not
intended, and should not be substituted for proper legal advice from an attorney.
You should, however, find that making
sure all necessary steps noted below are followed would reduce procedural difficulties and time delays.
I. INITIAL FILING:
A.
P
PETITION for (check one).
Petition for Support Unconnected with Dissolution of Marriage With Dependent or Minor Child(ren)
Form 12.904(a).
Petition for Support Unconnected With Dissolution of Marriage With No Dependent or Minor Child(ren)
Form 12.904(b).
Petition to Determine Paternity and for Related Relief - Form 12.983(a).
Petition for Change of Name (Adult)/Order - Form 12.982(a).
Petition for Change of Name (Minor Child)/Order - Form 12.982(c).
Petition for Change of Name (Family) - Form 12.982(f).
Other local form original petition: __________________________________________________________
B. Required forms filed with initial petition:
UCCJEA Affidavit - Form 12.902(d), is required in most matters involving children, including request for
the name change of a minor child. T
This form is not required if your petition only covers alimony.
Child Support Guideline Worksheet – Form 12.902(e), if your original petition is for paternity, or support
unconnected with dissolution of marriage with children, the matter of child support is normally
addressed. (If you do not know the other party’s income, you may file this worksheet after his or her
financial affidavit has been served to you.). T
This form is not required if your original petition only covers
alimony, or name change.
Financial Affidavit - Form 12.902(b) or 12.902(c) (according to your income-see instructions on form).
This form is not required if your petition only covers change of name, or grandparent visitation.
Non-military Affidavit - Form 12.912(b). T
This form is required only for obtaining a default on petitions
that have been personally or constructively served, not required with any joint form.
Corroborating Witness Affidavit - Form 12.902(i) or photocopy of Florida Drivers License, Florida
Identification Card, or Voters I.D. I
Issue date of copied document must be at least six months before
date case is filed with Clerk of Court.
Summons: Personal Service on an Individual – Form 12.910(a). N
Not required if both parties have
signed and filed a joint petition, if the other party has signed a consent, or in an adult name change
case.
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Process Service Memorandum - Form 12.910(b). If filing for grandparent visitation, b
both
natural or
adopted parents must be individually personally served with the petition. This is true even if your son or
daughter resides with you.
Service is not required in the following situations:
a) if both parties have signed and filed a joint petition.
b) when filing an Adult Name Change.
c) when filing a minor name change case if the other parent has signed a consent.
Out of State Service Information:
If service is required on a party residing outside of the state of Florida,
the party who filed the petition must obtain service procedure information including fees, from the local
officials responsible for process service where the other party resides. This information, along with
applicable fees (in the form of a money order), must be provided to the Clerk’s Office. The Clerk’s Office
will forward the completed summons and paperwork to the address you provide for the out of state
agency. M
Most other states will not honor a Florida $SSOLFDWRQIRU,QGLJHQW6WDWXV.
OR:
Consent for Change of Name (Minor Child(ren)) – Form 12.982(d). Signed by other parent and
notarized.

For Name Change Only.
Fingerprints are to be taken by a law enforcement agencyHOHFWURQLFDOO\.
C. Required fees.
Filing fee paid or fee waiver (ASSOLFDWRQRI,QGLJHQW6WDWXV) granted by &OHUNCourt.
Fees IRUVHUYLFHVKRXOGEHSDLGGLUHFWO\WRD3URFHVV6HUYHU
D. Required class
Completion of approved Parent Education and Family Stabilization Course. N
Note:
If one party resides in
another Florida county or out of state, the party must receive court approval to take the class available
in their area of residence. T
This class is only required for parties filing an original paternity action, or, if
the court has specifically ordered you to take this class.
If both parties have signed and filed a joint petition, or, if you are filing for an Adult Name Change,
you may skip Section II entitled, “Service of Process.” The remaining sections still apply.
E. Optional Forms.
Motion for Referral to General Magistrate - Form 12.920(a) (A General Magistrate is an Attorney
appointed by the Chief Judge to take testimony and make recommendations to a judge. The primary
purpose of having a General Magistrate hear family law matters is to reduce the cost of litigation and
speed up cases.)
Order of Referral to General Magistrate - Form 12.920(b).
II. SERVICE OF PROCESS:
A. Personal Service.
Summons returned “served” and the Original Return of Service has been filed by Clerk in your court file. If
you are filing grandparent visitation you need this document on each parent.
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After 20 days have passed from the day Respondent was served, check to see whether Respondent(s)
filed an answer or a
any
paper within the 20 day period. If yes, you may check this item. (
(If both checked,
skip to Section IV; if no answer filed, go to “B”)
If your summons is returned to the clerk “NOT SERVED”
1. A
Alias summons:
Return to the Clerk of Court to request an A
Alias
(2
nd
attempt at service) or P
Pluries
(3
rd
or more attempt at service) service to be processed by the clerk of court.
Complete Summons: Personal Service on an Individual-form 12.910(a).
Process Service memorandum–form 12.910(b).
If you are still unable to serve the other party
2.
. Con
structive Service
: is only to be used after you have completed an actual diligent search for the
other party and have been unable to locate them.
Constructive service is also known as “service by publication.” You will need a “Notice of Action”
appropriate to your case. The supreme court forms do not contain a notice of action for any type of
action except divorce, you will need to locate the appropriate form in a law library or have the
assistance of an attorney to prepare the proper document. The document must be posted or
published for 32 days before you can proceed further with your case.
Affidavit of Diligent Search and Inquiry 12.913(b).
Constructive service is not available for all procedures. If constructive service is used, the court may grant
only limited relief. In all cases it is best to have your petition personally served. This is a complicated area
of the Law and you may wish to consult with an attorney before using constructive service.
If proper service is not obtained, the court cannot hear your case.
B. Default.
Respondent failed to answer or file any paper after service.
Motion for Default filed with Clerk - Form 12.922(a) (no sooner than 25 days after date of service.) a
and
Default entered by Clerk.
Note:
If the other party has filed a
anything in the case
the clerk will not be able
to process the default. This is also true if the other party is a member of the military service. If the clerk
is unable to process your default, you will need to file a motion for the “court to enter the default” send
a copy to the other party and set a hearing on your motion. If you are filing a grandparent visitation case
you will complete this section for each parent that didn’t respond in writing.
Only now is the case potentially ready for setting for trial/final hearing.
III. FINANCIAL DISCLOSURE:
If your petition involves financial issues such as property, child support or alimony, each party has a right to the
production of certain documents during the discovery phase of the case. See Fla. Fam. L. R. P. 12.285. (
(This
section does not apply to name change, grandparent visitation, or stepparent adoption cases.)
Certificate of Compliance with Mandatory Disclosure - Form 12.932. The actual documents (tax returns,
pay stubs etc.) should not be filed in the court file. The documents should be provided to the other party
and this affidavit should be filed with the Clerk to notify the court that the listed documents have been
provided to the other party. You may be required to bring these documents with you to the hearing.
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Note:
If the other party refuses to provide you with their financial information, a motion to compel can be
filed with the court requesting the court to order the other party to provide you their financial
information.
O
OR:
Waiver of Mandatory Disclosure documents signed by both parties. This means that both parties agree
NOT to exchange these documents, however, the requirement to file financial affidavits cannot be
waived.
IV. SETTING A HEARING:
After an answer is filed or a Default has been entered, contact the following office to set your hearing. If
the other party filed a counterpetition you are required to respond to their counterpetition. If the other
party filed a motion to dismiss your petition, a hearing must be set (by either party) to address the
motion to dismiss before you can set a final hearing. Pending motions may also prevent your final
hearing from being set as they must sometimes be addressed before a final hearing.
Call the resource center at 727-582-7200 to request final hearing. Your court records will be viewed for
completeness and you will either be given a court calendar date or you will be given further instructions
for setting your final hearing.
Depending upon which Judge your case is assigned to, you may be required to prepare the Notice of
Hearing – please be sure that you have completed the c
certificate of service
section on the bottom of the
form. There is one notice of hearing in your package, if you need more they can be obtained from the
clerk of court for a fee or downloaded from
www.jud6.org
(Representing yourself in court section) for
free. You will need the free acrobat reader (available from www.adobe.com
) software installed on your
computer to access the forms on our web page.
Distribute as follows:
1) Original filed with Clerk’s Office
2) Copy to other party or their attorney (must be received 5 days prior
to the hearing
date).
3) Copy maint
ained fo
r your
use (option
a
l).
If you do not properly complete this step, your hearing could be delayed.
NOTE: IF YOU ARE INVOLVED IN OTH
E
R
CAS
E
S,
SUCH
AS AN ACTIVE DEPENDENCY CASE, YOUR CASE
COULD BE REFERRED TO A UNIFIED FAMILY COURT JUDGE FOR HEARING. IF THIS IS YOUR SITUATION,
PROCEDURES FOR SETTING A HEARING WILL BE SLIGHTLY DIFFERENT. PLEASE CONTACT THE
RESOURCE CENTER AT THE ABOVE PHONE NUMBER FOR ASSISTANCE.
V. FINAL HEARING:
A. Make arrangements for child care if applicable. Children not allowed to attend without prior Order, per Fla. Fam.
L. R. P. 12.403.
B. Bring to final hearing:
Stamped ($.60), pre-addressed legal size (9.5” business size) envelopes for each
party, one for each if before Judge, two for each if before General Master.
Driver’s License, Florida Identification Card or Voter’s Identification card.
C
Certified copies
of all previous court orders affecting children (custody, visitation, support, dependency),
or other matters in your case (Alimony, distribution of assets/liabilities) especially if those orders were
entered by a Court in another state or county.
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Pay stubs (from past 3 months), certified copies of other support orders that you are required to pay,
documentation of assets and liabilities.
Completed child support guideline worksheet, if your case includes custody or child support - Form
12.902(e).
If your petition involves child support (or custody) then a “Memorandum to Clerk” will need to be
completed. Please bring address information for yourself and the other party to the hearing.
Income Deduction Order and 2 copies, if case involves support.
Final Disposition Form (obtain from Clerk).
Other possible documents you may need.
If one of the other parties in the case is deceased you may
need a certified death certificate
to prove that fact. If your petition in any way concerns real property
(such as a house or piece of land) you may need the legal description of that piece of property at your
hearing.
VI. AFTER THE FINAL HEARING:
When can I expect my final paperwork to arrive?
If your hearing was before a general magistrate and both parties
appeared. for the final hearing, you will be asked at the end of the hearing if you wish to waive the objection period. If
you both agreed to waive the objection period, the general magistrate’s office prepares the order and sends it directly to
the judge. If both parties did not appear, or one party does not waive their opportunity to file objections, then you will first
receive a copy of the magistrate’s findings and recommendations in the mail shortly after the hearing. After 15 days, if
there is no objection, the findings and recommended order will be forwarded to the judge’s office for signature.
How do I get the support taken out of the other party’s paycheck?
Unless the other party is self-employed, income
deduction orders are usually entered in cases where support has been ordered. If your hearing was before the general
magistrate, your order is not final until you receive the “order confirming findings and recommendations of general
magistrate” in the mail after your hearing. Once you have received this order, it is generally your responsibility to contact
the clerk of court to obtain a “certified” copy of your income deduction order. It is then your responsibility to mail the
certified income deduction order to the employer. It is suggested that you use certified mail so you have proof that it was
received by the employer. If the other party changes jobs frequently, you may need to follow this procedure every time
they change jobs. The income deduction order is not made out to a specific job, it should be accepted by any employer
(note: this should include employers in other states). The income deduction order makes the employer a party to the
case.
The FLSDU:
The State of Florida Disbursement Unit handles all income deducted support payments for the State of
Florida. Their toll free automated number is 877-769-0251.
"If you are a person with a disability who needs any accommodation in order to participate in a court
proceeding, you are entitled, at no cost to you, to the provision of certain assistance. Within two (2)
working days of your receipt of any notice or order requiring your presence at a hearing, please
contact the Human Rights Office, 400 S. Ft. Harrison Ave., 5
th
Floor, Clearwater, FL 33756, (727)
464-4062 (V/TDD).”
General Information for Self-Represented Litigants (09/13)
- 1 -
FAMILY LAW FORMS, COMMENTARY, AND INSTRUCTIONS
GENERAL INFORMATION FOR SELF-REPRESENTED LITIGANTS
(09/13)
You should read this General Information thoroughly before taking any other steps to file your case or
represent yourself in court. Most of this information is not repeated in the attached forms. This
information should provide you with an overview of the court system, its participants, and its processes.
It should be useful whether you want to represent yourself in a pending matter or have a better
understanding of the way family court works. This is not intended as a substitute for legal advice from
an attorney. Each case has its own particular set of circumstances, and an attorney may advise you of
what is best for you in your individual situation.
These instructions are not the only place that you can get information about how a family case works.
You may want to look at other books for more help. The Florida Statutes, Florida Family Law Rules of
Procedure, Florida Rules of Civil Procedure, and other legal information or books may be found at the
public library or in a law library at your county courthouse or a law school in your area. If you are filing a
petition for Name Change and/or Adoption, these instructions may not apply.
If the word(s) is printed in bold, this means that the word is being emphasized. Throughout these
instructions, you will also find words printed in bold and underlined. This means that the definitions of
these words may be found in the glossary of common family law terms at the end of this general
information section.
Commentary
1995 Adoption. To help the many people in family law court cases who do not have attorneys
to represent them (pro se litigants), the Florida Supreme Court added these simplified forms and
directions to the Florida Family Law Rules of Procedure. The directions refer to the Florida Family Law
Rules of Procedure or the Florida Rules of Civil Procedure. Many of the forms were adapted from the
forms accompanying the Florida Rules of Civil Procedure. Practitioners should refer to the committee
notes for those forms for rule history.
The forms were adopted by the Court pursuant to Family Law Rules of Procedure, 667 So. 2d
202 (Fla. 1995); In re Petition for Approval of Forms Pursuant to Rule 10-1.1(b) of the Rules Regulating
the Florida Bar—Stepparent Adoption Forms, 613 So. 2d 900 (Fla. 1992); Rules Regulating the Florida
Bar—Approval of Forms, 581 So. 2d 902 (Fla. 1991).
Although the forms are part of these rules, they are not all-inclusive, and additional forms, as
necessary, should be taken from the Florida Rules of Civil Procedure as provided in Florida Family Law
Rules of Procedure. Also, the following notice has been included to strongly encourage individuals to
seek the advice, when needed, of an attorney who is a member in good standing of the Florida Bar.
1997 Amendment. In 1997, the Florida Family Law Forms were completely revised to simplify
and correct the forms. Additionally, the appendices were eliminated, the instructions contained in the
appendices were incorporated into the forms, and the introduction following the Notice to Parties was
created. Minor changes were also made to the Notice to Parties set forth below.
General Information for Self-Represented Litigants (09/13)
- 2 -
NOTICE TO PARTIES WHO ARE NOT REPRESENTED BY AN ATTORNEY WHO IS A
MEMBER IN GOOD STANDING OF THE FLORIDA BAR
If you have questions or concerns about these forms, instructions, commentary, the use of the forms,
or your legal rights, it is strongly recommended that you talk to an attorney. If you do not know an
attorney, you should call the lawyer referral service listed in the yellow pages of the telephone book
under “Attorney.” If you do not have the money to hire an attorney, you should call the legal aid
office in your area.
Because the law does change, the forms and information about them may have become outdated.
You should be aware that changes may have taken place in the law or court rules that would affect
the accuracy of the forms or instructions.
In no event will the Florida Supreme Court, The Florida Bar, or anyone contributing to the production
of these forms or instructions be liable for any direct, indirect, or consequential damages resulting
from their use.
FAMILY LAW PROCEDURES
Communication with the court. Ex parte communication is communication with the judge with only
one party present. Judges are not allowed to engage in ex parte communication except in very limited
circumstances, so, absent specific authorization to the contrary, you should not try to speak with or
write to the judge in your case unless the other party is present or has been properly notified. If you
have something you need to tell the judge, you must ask for a hearing and give notice to the other
party or file a written statement in the court file and send a copy of the written statement to the
other party.
Filing a case. A case begins with the filing of a petition. A petition is a written request to the court for
some type of legal action. The person who originally asks for legal action is called the petitioner and
remains the petitioner throughout the case.
A petition is given to the clerk of the circuit court, whose office is usually located in the county
courthouse or a branch of the county courthouse. A case number is assigned and an official court file is
opened. Delivering the petition to the clerk’s office is called filing a case. A filing fee is usually required.
Once a case has been filed, a copy must be given to (served on) the respondent. The person against
whom the original legal action is being requested is called the respondent, because he or she is
expected to respond to the petition. The respondent remains the respondent throughout the case.
Service. When one party files a petition, motion, or other pleading, the other party must be “served”
with a copy of the document. This means that the other party is given proper notice of the pending
action(s) and any scheduled hearings. Personal service of the petition and summons on the respondent
by a deputy sheriff or private process server is required in all original petitions and supplemental
petitions, unless constructive service is permitted by law. Personal service may also be required in
other actions by some judges. After initial service of the original or supplemental petition and summons
by a deputy sheriff or private process server, service of most motions and other documents or papers
filed in the case generally may be made by email, regular U.S. mail, or hand delivery. However, service
General Information for Self-Represented Litigants (09/13)
- 3 -
by certified mail is required at other times so you have proof that the other party actually received the
papers. The instructions with each form will advise you of the type of service required for that form. If
the other party is represented by an attorney, you should serve the attorney and send a copy to the
other party, except for original or supplemental petitions, which must be personally served on the
respondent.
Other than the original or supplemental petitions, any time you file additional pleadings or motions in
your case, you must provide a copy to the other party and include a certificate of service. Likewise, the
other party must provide you with copies of everything that he or she files. Service of additional
documents is usually completed by U.S. mail. For more information, see the instructions for Certificate
of Service (General), Florida Supreme Court Approved Family Law Form 12.914.
Forms for service of process are included in the Florida Family Law Forms, along with more detailed
instructions and information regarding service. The instructions to those forms should be read carefully
to ensure that you have the other party properly served. If proper service is not obtained, the court
cannot hear your case.
Note: If you absolutely do not know where the other party to your case lives, or if the other party
resides in another state, you may be able to use constructive service. However, if constructive service is
used, other than granting a divorce, the court may only grant limited relief, which cannot include either
alimony or child support. For more 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), Notice of Action for Family Cases with Minor Child(ren), Florida Supreme Court
Approved Family Law Form 12.913(a)(2), Affidavit of Diligent Search and Inquiry, Florida Family Law
Rules of Procedure Form 12.913(b), and Affidavit of Diligent Search, Florida Family Law Rules of
Procedure Form 12.913(c).. Additionally, 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 is very complex and you may wish to
consult an attorney regarding these issues.
Default... After being served with a petition or counterpetition, the other party has 20 days to file a
response. If a response to a petition is not filed, the petitioner may file a Motion for Default, Florida
Supreme Court Approved Family Law Form 12.922(a), with the clerk. This means that you may proceed
with your case and set a final hearing, and a judge will make a decision, even if the other party will not
cooperate. For more information, see rule 12.080(c), Florida Family Law Rules of Procedure.
Answer and Counterpetition... After being served, the respondent has 20 days to file an answer
admitting or denying each of the allegations contained in the petition. In addition to an answer, the
respondent may also file a counterpetition. In a counterpetition, the respondent may request the same
or some other relief or action not requested by the petitioner. If the respondent files a counterpetition,
the petitioner should then file an Answer to Counterpetition, Florida Supreme Court Approved Family
Law Form 12.903(d), and either admit or deny the allegations in the respondent’s counterpetition.
Mandatory disclosure... Rule 12.285, Florida Family Law Rules of Procedure, requires each party in a
dissolution of marriage to exchange certain information and documents, and file a Family Law Financial
Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or (c). Failure to make this required
disclosure within the time required by the Florida Family Law Rules of Procedure may allow the court to
dismiss the case or to refuse to consider the pleadings of the party failing to comply. This requirement
also must be met in other family law cases, except adoptions, simplified dissolutions of marriage,
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enforcement proceedings, contempt proceedings, and proceedings for injunctions for domestic or
repeat violence. The Certificate of Compliance with Mandatory Disclosure, Florida Family Law Rules of
Procedure Form 12.932, lists the documents that must be given to the other party. For more
information see rule 12.285, Florida Family Law Rules of Procedure, and the instructions to the
Certificate of Compliance with Mandatory Disclosure, Florida Family Law Rules of Procedure Form
12.932.
Parenting Plan. If your case involves minor or dependent child(ren), a Parenting Plan shall be approved
or established by the court. 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). The Parenting Plan shall be developed and agreed to by the parents and approved by a court.
If the parents cannot agree, or if the agreed Parenting Plan is not approved, the court must establish a
Parenting Plan. The Parenting Plan shall contain a time-sharing schedule and should address the issues
regarding the child(ren)’s education, health care, and physical, social, and emotional well-being.
Setting a hearing or trial. Generally, the court will have hearings on motions, final hearings on
uncontested or default cases, and trials on contested cases. Before setting your case for final hearing
or 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 jurisdiction. For further information, you should refer to the
instructions for the type of form you are filing.
Next, you must obtain a hearing or trial date so that the court may consider your request. You should
ask the clerk of court, or family law intake staff about the local procedure for setting a hearing or trial,
which you should attend. These family law forms contain orders and final judgments, which the judge
may use. You should ask the clerk of court or family law intake staff 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.
Below are explanations of symbols or parts of different family law forms...
{specify}, {date}, {name(s)}, {street}, {city}, {state}, {phone}
Throughout these forms, you will find hints such as those above. These tell you what to put in the
blank(s).
 one only] [all that apply]
These show how many choices you should check. Sometimes you may check only one, while other times
you may check several choices. ( ) This also shows an area where you must make a choice. Check the
( ) in front of the choice that applies to you or your case.
IN THE CIRCUIT COURT OF THE (1) JUDICIAL CIRCUIT,
IN AND FOR (2) COUNTY, FLORIDA
Case No.: (3)
Division: (4)
(5) ,
Petitioner,
and
(6) ,
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Respondent.
Line 1 The clerk of court can tell you the number of your judicial circuit. Type or print it here.
Line 2 Type or print your county name on line (2).
Line 3 If you are filing an initial petition or pleading, the Clerk of the Court will assign a case number
after the case is filed. You should type or print this case number on all papers you file in this
case.
Line 4 The clerk of the court can tell you the name of the division in which your case is being filed, and
you should type or print it here. Divisions vary from court to court. For example, your case may
be filed in the civil division, the family division, or the juvenile division.
Line 5 Type or print the legal name of the person who originally filed the case on line 5. This person is
the petitioner because he/she is the one who filed the original petition.
Line 6 Type or print the other party’s legal name on line 6. The other party is the respondent because
he/she is responding to the petition.
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: (1) (2) (2)
Signature of Petitioner
Printed Name: (3)
Address: (4)
City, State, Zip: (5)
Telephone Number: (6)
Fax Number: (7)
Email Address:________________(8)_______________
Some forms require that your signature be witnessed. You must sign the form in the presence of a
notary public or deputy clerk (employee of the clerk of the court’s office). When signing the form, you
must have a valid photo identification unless the notary knows you personally. You should completely
fill in all lines (1 & 3–8) except 2 with the requested information, if applicable. Line 2, the signature line,
must be signed in the presence of the notary public or deputy clerk.
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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
DO NOT SIGN OR FILL IN THIS PART OF ANY FORM. This section of the form is to be completed by the
notary public who is witnessing your signature.
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: {either Petitioner or Respondent; or Husband or Wife}
This form was completed with the assistance of:
{name of individual }________(1)________________________________________________________,
{name of business} _____________(2)____________________________________________________,
{address} (3) ___________________________________________,
{city} (4)______________,{state} (5), {telephone number} _(6)____________________.
This section should be completed by anyone who helps you fill out these forms but is not an attorney
who is a member in good standing of The Florida Bar, which means that he or she is not licensed to
practice law in Florida.
Line 1 The nonlawyer who helps you should type or print his or her name on line 1.
Lines 2–6 The nonlawyer’s business name, address, (including street, city, state, and telephone
number) should be typed or printed on lines 2–6.
In addition, a Disclosure from Nonlawyer, Florida Family Law Rules of Procedure Form 12.900(a), should
be completed if a nonlawyer assists you. The disclosure is available as a family law form and should be
completed before the nonlawyer helps you. This is to be sure that you understand the role and
limitations of a nonlawyer. You and the nonlawyer should keep a copy of this disclosure for your
records.
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FAMILY LAW GLOSSARY OF COMMON TERMS AND DEFINITIONS
Note: The following definitions are intended to be helpful, BUT they are not intended to constitute
legal advice or address every possible meaning of the term(s) contained in this glossary.
Affidavit - a written statement in which the facts stated are sworn or affirmed to be true.
Alimony-spousal support which may be ordered by the court in a proceeding for dissolution of marriage.
Types of alimony include: bridge-the-gap, durational, rehabilitative, or retroactive and may be either
temporary or permanent. The court may order periodic payments, payment in lump sum, or both. In
determining whether to award alimony, the court must determine whether either party has an actual
need for alimony and whether the other party has the ability to pay. The court must consider the
factors set forth in section 61.08, Florida Statutes, and must make certain written findings. An alimony
award may not leave the paying party with significantly less net income than that of the receiving party
without written findings of exceptional circumstances.
Answer - written response by a respondent that states whether he or she admits (agrees with) or denies
(disagrees with) the allegations in the petition. Any allegations not specifically denied are considered to
be admitted.
Appeal - asking a district court of appeal to review the decision in your case. There are strict procedural
and time requirements for filing an appeal.
Asset - everything owned by you or your spouse, including property, cars, furniture, bank accounts,
jewelry, life insurance policies, businesses, or retirement plans. An asset may be marital or nonmarital,
but that distinction is for the court to determine if you and your spouse do not agree.
Attorney - a person with special education and training in the field of law who is a member in good
standing of The Florida Bar and licensed to practice law in Florida. An attorney is the only person who is
allowed to give you legal advice. An attorney may file your case and represent you in court, or just
advise you of your rights before you file your own case. In addition to advising you of your rights, an
attorney may tell you what to expect and help prepare you for court. In family law matters, you are not
entitled to a court-appointed lawyer, like a public defender in a criminal case. However, legal assistance
is often available for those who are unable to hire a private attorney. You may consult the yellow pages
of the telephone directory for a listing of legal aid or lawyer referral services in your area, or ask your
local clerk of court or family law intake staff what services are available in your area. You may also
obtain information from the Florida Supreme Court’s Internet site located at http://www.flcourts.org.
Bond - money paid to the clerk of court by one party in a case, to be held and paid to an enjoined party
in the event that the first party causes loss or damage of property as a result of wrongfully enjoining the
other party.
Beneficiary Designation-Florida law provides that a beneficiary designation made by or on behalf of a
party providing for the payment or transference of an asset or benefit upon his or her death to the other
spouse is void when the final judgment dissolving or declaring a marriage invalid is signed, unless the
final judgment specifically states otherwise. Federal law and other statutory provisions may also apply.
This includes, but is not limited to, such assets as life insurance policies, annuities, employee benefit
plans, individual retirement accounts, and payable-on-death accounts. Whether or not to continue a
beneficiary designation is a complex area of the law and you may wish to consult with an attorney.
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Bridge-the-Gap Alimony-spousal support which is ordered to assist a party to make the transition from
being married to being single. Bridge-the-Gap alimony is designed to assist a party with legitimate,
identifiable short-time needs; its length cannot exceed two years and it cannot be modified.
Central Depository-the office of the clerk of court that is responsible for collecting and disbursing court
ordered alimony and child support payments. The depository also keeps payment records and files
judgments if support is not paid.
Certificate of Service - a document that must be filed whenever a form you are using does not contain a
statement for you to fill in showing to whom you are sending copies of the form. Florida Supreme Court
Approved Family Law Form 12.914 is the certificate of service form and contains additional instructions.
Certified Copy - a copy of an order or final judgment, certified by the clerk of the circuit court to be an
authentic copy.
Certified Mail - mail which requires the receiving party to sign as proof that they received it.
Child Support - money paid from one parent to the other for the benefit of their dependent or minor
child(ren).
Clerk of the Circuit Court - elected official in whose office papers are filed, a case number is assigned,
and case files are maintained. The clerk’s office usually is located in the county courthouse.
Concurrent Custody-(for the purposes of a petition filed pursuant to chapter 751, Florida Statutes)
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.
Constructive Service - notification of the other party by newspaper publication or posting of notice at
designated places when the other party cannot be located for personal service. You may also be able to
use constructive service when the other party lives in another state. Constructive service is also called
“service by publication.” However, when constructive service is used, the relief the Court may grant is
limited; that relief cannot include either alimony or child support. For more information on service, see
the Instructions for 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).
Contested Issues - any or all issues upon which the parties are unable to agree and which must be
resolved by the judge at a hearing or trial.
Contingent Asset - an asset that you may receive or get later, such as income, tax refund, accrued
vacation or sick leave, a bonus, or an inheritance.
Contingent Liability - a liability that you may owe later, such as payments for lawsuits, unpaid taxes, or
debts that you have agreed or guaranteed to pay if someone else does not.
Counterpetition - a written request to the court for legal action, which is filed by a respondent after
being served with a petition.
Custody Order - a judgment or order incorporating a 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. ss. 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.
Default - a failure of a party to respond to the pleading of another party. This failure to respond may
allow the court to decide the case without input from the party who did not appear or respond.
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Delinquent - late.
Dependent Child(ren) - child(ren) who depend on their parent(s) for support either because they are
under the age of 18, have a mental or physical disability that prevents them from supporting
themselves, or are in high school, between the ages of 18 and 19, and performing in good faith with a
reasonable expectation of graduation before the age of 19.
Deputy Clerk - an employee of the office of the clerk of court, which is usually located in the county
courthouse or a branch of the county courthouse.
Dissolution of Marriage - divorce; a court action to end a marriage.
Durational Alimony-spousal support which is ordered to provide economic assistance for a set period of
time following a marriage of short or moderate duration or following a marriage of long duration if there
is no ongoing need for support on a permanent basis. Durational alimony terminates upon the death of
either party or upon remarriage of the party receiving support. It may be modified or terminated, but
cannot exceed the length of a marriage.
Electronic Communication -Contact, other than face-to-face contact, facilitated by tools such as
telephones, electronic mail or email, webcams, video-conferencing equipment, and software or other
wired or wireless technologies, or other means of communication to supplement fact-to face contact
between a parent and that parent’s minor child.
Enjoined - prohibited by the court from doing a specific act.
Ex Parte - communication with the judge by only one party. In order for a judge to speak with either
party, the other party must have been properly notified and have an opportunity to be heard. If you
have something you wish to tell the judge, you should ask for a hearing or file information in the clerk of
court’s office, with certification that a copy was sent to the other party.
Extended Family-(for the purposes of a petition filed pursuant to chapter 751, Florida Statutes) is a
person who is either:
1) A relative of a minor child within the third degree by blood or marriage to the parent; OR
2) 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’s parents as an adverse party.
Family Law Intake Staff - a court’s employee(s) who is (are) available to assist you in filing a family law
case. Family law intake staff are not attorneys and cannot give legal advice. They may only assist you
with filling out the form(s). Your local clerk’s office can tell you if your county has such assistance
available.
Filing - delivering a petition, response, motion, or other pleading in a court case to the clerk of court’s
office.
Filing Fee - an amount of money, set by law, that the petitioner must pay when filing a case. If you
cannot afford to pay the fee, you must file an Application for Determination of Civil Indigent Status, to
ask the clerk to file your case without payment of the fee. This form can be obtained from the clerk’s
office.
Final Hearing - trial in your case.
Financial Affidavit - a sworn statement that contains information regarding your income, expenses,
assets, and liabilities.
Final Judgment - a written document signed by a judge and recorded in the clerk of the circuit court’s
office that contains the judge’s decision in your case.
Guardian ad Litem - a neutral person who may be appointed by the court to evaluate or investigate your
child’s situation, and file a report with the court about what is in the best interests of your child(ren).
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Guardians do not “work for” either party. The guardian may interview the parties, visit their homes,
visit the child(ren)’s school(s) and speak with teachers, or use other resources to make their
recommendation.
Hearing - a legal proceeding before a judge or designated officer (general magistrate or hearing officer)
on a motion.
Health Insurance-coverage under a fee-for-service arrangement, health care maintenance organization,
or preferred provider organization, and other types of coverage available to either parent, under which
medical services could be provided to a minor or dependent child.
Judge - an elected official who is responsible for deciding matters on which you and the other parties in
your case are unable to agree. A judge is a neutral person who is responsible for ensuring that your case
is resolved in a manner which is fair, equitable, and legal. A judge is prohibited by law from giving you
or the other party any legal advice, recommendations, or other assistance, and may not talk to either
party unless both parties are present, represented, or at a properly scheduled hearing.
Judicial Assistant - the judge’s personal staff assistant.
Liabilities - everything owed by you or your spouse, including mortgages, credit cards, or car loans. A
liability may be marital or nonmarital, but that distinction is for the court to determine if you and your
spouse do not agree.
Lump Sum Alimony - money ordered to be paid by one spouse to another in a limited number of
payments, often a single payment.
Mandatory Disclosure - items that must be disclosed by both parties except those exempted from
disclosure by Florida Family Law Rule 12.285.
Marital Asset - generally, anything that you and/or your spouse acquired or received (by gift or
purchase) during the marriage. For example, something you owned before your marriage may be
nonmarital. An asset may only be determined to be marital by agreement of the parties or
determination of the judge.
Marital Liability - generally, any debt that you and/or your spouse incurred during the marriage. A debt
may only be determined to be nonmarital by agreement of the parties or determination of the judge.
Mediator - a person who is trained and certified to assist parties in reaching an agreement before going
to court. Mediators do not take either party’s side and are not allowed to give legal advice. They are
only responsible for helping the parties reach an agreement and putting that agreement into writing. In
some areas, mediation of certain family law cases may be required before going to court.
Modification - a change made by the court in an order or final judgment.
Motion - a request made to the court, other than a petition.
No Contact - a court order directing a party not speak to, call, send mail to, visit, or go near his or her
spouse, ex-spouse, child(ren), or other family member.
Nonlawyer - a person who is not a member in good standing of The Florida Bar.
Nonmarital Asset - generally, anything owned separately by you or your spouse. An asset may only be
determined to be nonmarital by either agreement of the parties or determination of the judge.
Nonmarital Liability - generally, any debt that you or your spouse incurred before your marriage or
since your separation. A debt may only be determined to be nonmarital by either agreement of the
parties or determination of the judge.
Nonparty - a person who is not the petitioner or respondent in a court case.
Notary Public - a person authorized to witness signatures on court-related forms.
Obligee - a person to whom money, such as child support or alimony, is owed.
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Obligor - a person who is ordered by the court to pay money, such as child support or alimony.
Order - a written decision signed by a judge and filed in the clerk of the circuit court’s office, that
contains the judge’s decision on part of your case, usually on a motion.
Original Petition - see Petition.
Parenting Course - a class that teaches parents how to help their child(ren) cope with divorce and other
family issues.
Parenting Plan – a document created to govern the relationship between the parents relating to the
decisions that must be made regarding the minor child(ren). The Parenting Plan must contain a time-
sharing schedule for the parents and child(ren) and shall address the issues concerning the minor
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 factors must be taken into consideration. The Parenting Plan must be developed and agreed to by
the parents and approved by the court. If the parents 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.
Parenting Plan Recommendation – A nonbinding recommendation concerning one or more elements of
a Parenting Plan made by a court-appointed mental health practitioner or other professional designated
pursuant to either section 61.20 or 61.401, Florida Statutes, or Florida Family Law Rule of Procedure
12.363.
Party - a person involved in a court case, either as a petitioner or respondent.
Paternity Action - A lawsuit used to determine whether a designated individual is the father of a specific
child or children.
Payor - an employer or other person who provides income to an obligor.
Permanent Alimony - spousal support ordered to provide for the needs and necessities of life as they
were established during the marriage for a party who lacks the financial ability to meet his or her needs
and necessities after dissolution of marriage. Permanent alimony is paid at a specified, periodic rate
until: modification by a court order; the death of either party; or the remarriage of the party receiving
alimony, whichever occurs first. Permanent alimony requires consideration of the factors set forth in
section 61.08(2), Florida Statutes, and must include certain written findings by the court.
Personal Service - when a summons and a copy of a petition (or other pleading) that has been filed with
the court are delivered by a deputy sheriff or private process server to the other party. Personal service
is required for all petitions and supplemental petitions.
Petition - a written request to the court for legal action, which begins a court case.
Petitioner - the person who files a petition that begins a court case.
Pleading - a formal written statement of exactly what a party wants the court to do in a lawsuit or court
action.
Pro Se or Self-Represented Litigant - a person who appears in court without the assistance of a lawyer.
Pro Se Coordinator - see Family Law Intake Staff.
Rehabilitative Alimony - spousal support ordered to be paid for a limited period of time to allow one of
the parties an opportunity to complete a plan of education or training, according to a rehabilitative plan
accepted by the court, so that he or she may better support himself or herself after dissolution of
marriage.
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Relocation- a change in the location of the principal residence of a parent or other person in accordance
with section 61.13001, Florida Statutes.
Respondent - the person who is served with a petition requesting some legal action against him or her.
Scientific Paternity Testing - a medical test to determine who the father of a child is.
Service - the delivery of legal documents to a party. Service must be in accordance with Florida Rule of
Judicial Administration 2.516.
Shared Parental Responsibility - an arrangement under which both parents have full parental rights and
responsibilities for their child(ren), and the parents make major decisions affecting the welfare of the
child(ren) jointly. Shared Parental Responsibility is presumptive in Florida.
Sole Parental Responsibility - a parenting arrangement under which the responsibility for the minor
child(ren) is given to one parent by the court, with or without rights of time-sharing to the other parent.
State Disbursement Unit- the unit established and operated by the Title IV-D agency to provide one
central address for the collection and disbursement of child support payments made in both
Department of Revenue and non-Department of Revenue cases, in which the obligation is paid through
an income deduction order.
Supervised Time-Sharing- a parenting arrangement under which time-sharing between a parent and his
or her child(ren) is supervised by either a friend, family member, or a supervised visitation center.
Supplemental Petition - a petition that may be filed by either party after the judge has made a decision
in a case and a final judgment or order has been entered. For example, a supplemental petition may be
used to request that the court modify the previously entered final judgment or order.
Supportive Relationship-a relationship, defined in section 61.14(1)(b)1, Florida Statutes, existing
between a spouse who receives alimony and a person with whom that spouse resides.
Time-Sharing Schedule – a timetable that must be included in the Parenting Plan that specifies the time,
including overnights and holidays, that a minor child or children will spend with each parent. The time-
sharing schedule shall either be developed and agreed to by the parents of a minor child or children and
is approved by the court, or established by the court if the parents cannot agree, or if their agreed-upon
schedule is not approved by the court.
Trial - the final hearing in a contested case.
Uncontested - any and all issues on which the parties are able to agree and which are part of a marital
settlement agreement.
1
THE MEDIATION PROCESS
INSTRUCTIONS FOR FAMILY LAW CASES
Authority: Pursuant to §44.1011 and 44.108 Fla. Stat., and Fla. Fam. L. R. P. 12.740, et seq., judges
have the authority to order all contested family matters and issues to mediation.
To help make mediation more accessible to all parties, Chapter 2004-265, Laws of Florida, amended
44.108 Florida Statutes. Through funding for the State Court System, the Sixth Judicial Circuit will
implement Fl Stat 44.108 with a mediation model that provides paid family and county civil mediation
services to certain parties.
Definition: Mediation is statutorily defined as “...[A] process whereby a neutral third person called a
mediator acts to encourage and facilitate the resolution of a dispute between two or more parties.”
It is an informal and nonadversarial process with the objective of helping the disputing parties reach a
mutually acceptable and voluntary agreement. In mediation, decision making authority rests with the
parties. The role of the mediator includes, but is not limited to, assisting the parties in identifying issues,
fostering joint problem solving, and exploring settlement alternatives.
The mediator has no decision making power. Any agreement reached will be by mutual consent of the
parties. A written agreement that is signed may be filed and submitted to the court with the parties
consent.
Special Rules or Procedures: For each case referred to family mediation, parties eligible for court
provided mediation shall select either privately retained mediation or court provided mediation services.
Parties not eligible for court provided mediation shall select their own mediator and hold a mediation
conference in accordance with the order of referral. In accordance with Family Law Rule of Procedure
12.741 (b)(6)(A) and Rule of Civil Procedure 1.710(f)(1), eligible and non-eligible parties may choose
their own mediator; however the selection must occur within ten(10) days of the order of referral.
Court Provided Mediation Services
Requirements:
To determine eligibility for court provided mediation, both parties must submit a
Family Law Financial Affidavit 12.902(b)-Short Form upon receipt of this notice that is no more
than six months old. The form can be obtained
http://www.flcourts.org/core/fileparse.php/293/urlt/902b.pdf
A general income statement, for the purpose of determining eligibility for court-provided
mediation only, is available from the mediation staff or online at
www.jud6.org/ContactInformation/AlternativeDisputeResolution.html
The financial affidavits must be notarized and mailed or emailed to the Mediation
Program either to our St Petersburg (for St Pete Judge cases) office 501 1
st
Avenue
No., Room 722, St Petersburg, FL 33701 or Email to: smorrison@jud6.org , or our
Clearwater office (for Clearwater Judge cases) at 315 Court St., Room 401,
Clearwater, FL 33756 or Email to: jpadoll@jud6.org.
1. After you submit the financial affidavit, contact the mediation office at (727) 464-4947 for a
determination of eligibility and the assignment of the mediator. The Program will select a family
mediator by rotation from the court contracted list. You shall have ten days to schedule the date,
time and location of the mediation conference with the mediator, and pay the clerk the required
mediation fee.
2. You shall contact the Mediation Program office with the above information within the specified ten
days. If you do not notify the Program within ten days, you will be given another ten days to select a
private mediator at an agreed upon rate of pay that you will pay directly to the mediator. If you fail to
notify the Program with this information within ten days, the Program will select a private mediator
2
by rotation, set the date, time and location of the mediation without contacting the parties, at the rate
of not more than $200.00 per hour.
Parties deemed otherwise eligible for court provided mediation may also opt instead to retain private
mediation, in which case the mediation fees below will not apply.
Mediation Fees
Fees are established by statute and are as follows:
$60.00 per person per session in family mediation when the parties’ combined gross income is less than
$50,000.00 per year.
$120.00 per person per session in family mediation when the parties’ combined gross income is greater
than $50,000.00 but less than $100,000.00 per year.
Any party may pay any other party’s mediation fee. A mediation fee collected from any party is
nonrefundable.
Parties must take a copy of the order of referral to one of the offices of the Clerk of Circuit Court in
Pinellas County and pay the designated fee in the order within ten days of receiving the order of referral.
Important: Keep and bring receipt of payment to the mediation conference.
Staff will also prepare notices reflecting your coordinated date and mediator that will be mailed to both
parties and the mediator.
Clerk of Circuit Court locations for payment of fees:
545 1
st
Avenue North, First Floor St. Petersburg, FL 33701 (727) 464-7000
or
315 Court Street, First Floor, Clearwater, FL 33756 (727) 464-7000
Private Mediation
If the parties choose their own private mediator, they may select a mutually acceptable mediator from the
list of certified mediators upon a stipulation with the court or by selecting a mediator who does not meet
the certification requirements, but who, in the opinion of the parties and upon review by the presiding
judge, is otherwise qualified by training or experience to mediate all or some of the issues in the particular
case. Parties must select a mediator and notify the Program of this selection within ten days of receipt of
the order of referral, or the Program will select a mediator for you. The parties and the mediator agree
upon a fee, and the parties pay the mediator at the time of the mediation.
The parties must coordinate with the mediator a date and time of mediation and notify the
Program. Staff will also prepare notices reflecting your coordinated date and mediator selection.
Mediation conferences generally last three hours and are scheduled from 9:00 a.m. until 12:00 p.m.
or 1:00 p.m. until 4:00 p.m., unless otherwise requested. Please see below for more detailed
information regarding our scheduling policies.
Procedures Applicable to Both Court-Provided Family Mediation and Private Family Mediation
Appearances: Unless otherwise stipulated by the parties, a named party must be physically present at
the mediation conference. In the discretion of the mediator, and with the agreement of the parties,
mediation may proceed in the absence of counsel unless otherwise ordered by the court.
The Conference: ATTORNEYS SHOULD SUBMIT A BRIEF WRITTEN SUMMARY OF THE
FACTS/ISSUES OF THE CASE TO THE MEDIATOR AT LEAST ONE WEEK BEFORE THE
SCHEDULED CONFERENCE. During the conference, counsel should be prepared to discuss the facts
and legal issues involved in the case and to generally help the parties evaluate the case. The ultimate
3
decision making authority of whether or not to settle the case rests with the parties, with the advice of
counsel.
IMPORTANT: The parties shall bring a copy of their financial affidavits to the mediation. If the case
involves child support, the parties shall bring to the mediation conference a Child Support Guidelines
Worksheet in substantial conformity with Florida Family Law Form 12.902 (e).
Upon motion or request of any party, the Court will not refer a case to mediation if it finds there
has been a history of domestic violence that would compromise the mediation process. The Court
on its own motion may determine that a case will not be referred to mediation because of a history
of domestic violence.
If the case involves parental responsibility and primary residence of the children, a parenting plan
proposal shall be exchanged between the parties five (5) to seven (7) days prior to the mediation
conference. The Florida Supreme Court approved parenting plans may be accessed at
www.jud6.org/ContactInformation/AlternativeDisputeResolution.html
Your mediator will be explaining the process in greater detail the day of the conference. In the meantime,
if you have any questions about these or any other court-ordered mediation procedures, you should call
the mediation program that is handling your case St. Petersburg (727) 582-7206.
PLEASE READ CAREFULLY
Scheduling, rescheduling and cancellations: The rules require that mediation be completed within 75
days of the initial mediation conference unless otherwise ordered by the court. The initial mediation
conference shall be held within sixty (60) days of the signed referral order.
The party or attorney who is requesting that a mediation session be rescheduled must obtain consent from
opposing counsel and the assigned mediator. The Program must also be notified of any rescheduling
attempts. If opposing counsel and/or the mediator do not give consent to reschedule the conference, the
attorney must apply for relief through the presiding judge prior to the scheduled conference. Cancellation
(with no attempt to reschedule) of the mediation conference will only be permitted where one or both
parties have applied for relief from the presiding judge and has had the case properly deferred or removed
from mediation. NO OTHER UNILATERAL CANCELLATION OR RESCHEDULING WILL BE
PERMITTED AND IS A VIOLATION OF THE COURT’S ORDER TO ATTEND.
Notifying the Mediator: The mediator must be notified at least forty-eight (48) hours in advance (not
including weekends and holidays) of any rescheduling or cancellation, for whatever reason. If the late
cancellations was due to a unilateral request through the court for a continuance or deferment, the moving
party may be assessed the entire cancellation fee. If the late rescheduling was due to a stipulation
between parties, any fee charged by the mediator (excludes cases involving a court mediator) will be
divided equally between or among them.
Settlement Prior to Mediation: Settlement before mediation is always encouraged but is still considered
a cancellation. Consequently, the forty-eight (48) hours notice requirement applies. It is the
responsibility of plaintiff’s counsel to notify the Program and the mediator in a timely manner of any
settlement before the initial conference. Written confirmation is required by the court order.
Payment: If the parties choose to utilize a court mediator, the fee of $60.00 or $120.00 per party
must be paid prior to the mediation conference. See page 1 for requirements regarding fees.. If the
parties choose their own private mediator in the absence of a written fee agreement providing for the
private mediator’s compensation, the mediator shall be paid at the rate of not more than $200.00 per hour.
Payment of the agreed fee is due to the mediator on the day of the mediation conference.
01/2016
Administrative Office of the Courts
The Sixth Judicial Circuit of Florida
(727)582-7200
How can I keep my address confidential in a court case if I am in fear
of domestic violence?
Question: I am in fear of domestic violence from my spouse or another party in my court case. What do I have to
do if I want to keep my address confidential?
Answer: In a domestic or repeat violence injunction case, the clerk of court has procedures in place to keep your
address confidential. If a party in the injunction case properly files their pleadings at the domestic violence desk, the
clerk will send you the copies of their pleadings so that you are properly notified of the filing and the hearing.
In most types of proceedings, the confidential address procedure through the clerk is not available
because parties
are required to copy other parties with pleadings filed in the case. In addition to sending copies of all pleadings, the
moving party must prepare a notice of hearing and send it to all parties in the case.
If you do not want the other party(s) to have your home address you can consider the following:
1. Obtain a post office box. The post office cannot reveal the true address of a post office box owner, who is
a p
rivate person and not a business, without a court order.
2. Ask your employer if you may use your work address to receive mail on your court case and as your
service address for personal service.
3. If you are a victim of domestic violence or the guardian of an adult, minor child or impaired person who is
a victim of domestic violence, you may inquire about the Address Confidentiality Program (ACP) with the
Florida Attorney General’s Office. You will be interviewed for acceptance into the program. Please call
the Florida Attorney General at 1-800-226-6667 (local # 850-414-3300, TDD/TTY users may use the
Florida Relay service at 1-800-955-8771) for information on setting up the interview.
How the program works:
If you are accepted into the ACP program you will be given a substitute address
to use for your mailing and legal process service address. The Attorney General will be the only one who
has your real address. All first class mail sent, or legal process served, to the substitute ACP address will
be forwarded to you by the Attorney General’s Office. Your acceptance into the program is for a set period
of time, is revocable, and must be renewed upon expiration. If you are accepted into the ACP program you
will be given an identification card. It is your responsibility to determine who will get your actual address
and who will get your ACP address. Government agencies are required to accept your ACP address but if
you have previously given your
actual address, they may not have to replace it with your substitute address
.
The courts may order you to reveal your true address during a court case. Be aware that many government
agencies
share information and if you have given your true address to one, it may be shared with other
agencies. Federal agencies and private businesses are not required to accept your ACP address but many
will do so. Certain agencies, such as law enforcement, have the right to access your true address for certain
reasons. A false or incorrect application under this program constitutes a second degree misdemeanor.
Sixth Judicial Circuit-Courts Information and Resource Center Reviewed 2/06
Administrative Office of the Courts F The Sixth Judicial Circuit of Florida F 727-582-7200
Sixth Judicial Circuit-Courts Information & Resource Center 11-2007 - updated 3/2011
South Pinellas County(St. Petersburg)
Name Address Telephone Number(s) or other information
Courts Information and
Resource Center
Family law procedural assistance &
information on approved forms.
727-582-7200 (walk-in assistance is not available)
Office hours 8 a.m .to Noon, 1 p.m. to 5 p.m. Monday - Friday.
Lawyer Referral Service
727-821-5450 (30 min. consultation with a lawyer for a small fee)
Legal Aid
St. Petersburg
Bay Area Legal Services-West
2600-9
th
Street North, Ste. 401
St. Petersburg, FL 33704
Bay Area Legal Services-West: 727-490-4040
Gulfcoast Legal Services: 727-821-0726
Community Law Program: 727-582-7402
St. Petersburg Courthouse
545-1
st
Avenue North
St. Petersburg, FL 33701
Clerk of Court: 727-464-7000
Child Support Automated Information Line: 727-464-4845
Alternative Dispute
Resolution Programs
Court ordered civil mediation and
arbitration services.
Mediation/Arbitration: 727-464-4943, Family Mediation: 727-464-4947
Clerk of Court Self Help
Center (St. Petersburg)
Legal assistance by
appointment for a fee
St. Petersburg Courthouse, 545-1
st
Avenue North, St. Petersburg,
FL 33701 phone: 727-582-7941 , call for information.
North Pinellas County(Clearwater)
Clearwater Courthouse
315 Court Street
Clearwater, FL 33756
Clerk of Court: 727-464-7000
Child Support Automated Information Line: 727-464-4845
Courts Information and
Resource Center
Family law procedural assistance &
information on approved forms.
727-582-7200 (walk-in assistance is not available)
Office hours 8 a.m. to Noon, 1 p.m. to 5 p.m. Monday - Friday.
Lawyer Referral Service
727-461-4880 (30 minute consultation for a small fee)
Legal Aid
Clearwater
Gulfcoast Legal Services
2189 Cleveland St., Bldg G, Ste.210
Clearwater, FL 33765
727-443-0657
Pinellas County Information
315 Court Street
Clearwater, FL 33756
727-464-3000
Alternative Dispute
Resolution Programs
Court ordered mediation and
arbitration services.
Mediation/Arbitration: 727-464-4943, Family Mediation: 727-464-4947
Clerk of Court Self Help
Center (Clearwater)
Legal assistance by
appointment for a fee
Clearwater Courthouse, 315 Court Street, Clearwater, FL 33756
phone: 727-464-5150 call for information.
Pasco County (New Port Richey & Dade City)
Clerk of Court-Civil
(New Port Richey)
7530 Little Road
New Port Richey, FL 34654
727-847-8176
727-847-2411
Clerk of Court-Civil
(Dade City)
38053 Live Oak Avenue
Dade City, FL 33523-3805
352-521-4517
Legal Aid-Pasco
Bay Area Legal Services
Offices in New Port Richey and
Dade City
New Port Richey: 727-847-5494
Dade City: 352-567-9044
Pasco County General
Information
38053 Live Oak Avenue
Dade City, FL 33523-3805
352-521-4274
Miscellaneous
Florida Dept. of Revenue
Many offices statewide
Child Support Enforcement: 850-488-5437
211
Information and referral for a
variety of state, local and private
services.
Dial 211 (24 hours per day, 7 days per week)
Multilingual Internet page: http://www.211tampabay.com
Internet Pages
Florida Supreme Court http://www.flcourts.org
,
Pinellas County Clerk of Court http://www.mypinellasclerk.org
Sixth Judicial Circuit Court http://www.jud6.org
,
Sixth Judicial Circuit Family Division
http://www.jud6.org/GeneralInfo/Abo
utTheCircuit/AOC/Courtprograms/familyLaw/familylaw.htm
State of Florida FLSDU
SDU
P.O. Box 8500
Tallahassee, FL 32314-8500
For income deducted support payments
1-877-769-0251 Toll free (you will need your case number and
social security number)
Instructions for Florida Family Law Rules of Procedure Form 12.900(a), Disclosure from Nonlawyer
(11/12)
INSTRUCTIONS FOR FLORIDA FAMILY LAW RULES OF PROCEDURE
FORM 12.900(a), DISCLOSURE FROM NONLAWYER (11/12)
When should this form be used?
This form must be used when anyone who is not a lawyer in good standing with The Florida Bar
helps you complete any Florida Family Law Form. Attorneys who are licensed to practice in
other states but not Florida, or who have been disbarred or suspended from the practice of law
in Florida, are nonlawyers for the purposes of the Florida Family Law Forms and instructions.
The nonlawyer must complete this form and both of you are to sign it before the nonlawyer
assists you in completing any Family Law Form.
In addition, on any other form with which a nonlawyer helps you, the nonlawyer shall complete
the nonlawyer section located at the bottom of the form unless otherwise specified in the
instructions to the form. This is to protect you and be sure that you are informed in advance of
the nonlawyer’s limitations.
What should I do next?
A copy of this disclosure, signed by both the nonlawyer and the person, must be given to the
person to retain and the nonlawyer must keep a copy in the person’s file. The nonlawyer shall
also keep copies for at least 6 years of all forms given to the person being assisted.
Special Notes
This disclosure form does NOT act as or constitute a waiver, disclaimer, or limitation of liability.
Florida Family Law Rules of Procedure Form 12.900(a), Disclosure From Nonlawyer (11/12)
IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL CIRCUIT,
IN AND FOR PINELLAS COUNTY, FLORIDA
Case No.: ________________________
Division: ________________________
_______________________________,
Petitioner,
and
_______________________________,
Respondent.
DISCLOSURE FROM NONLAWYER
{Name} __________________________________________ told me that he/she is a nonlawyer
and may not give legal advice, cannot tell me what my rights or remedies are, cannot tell me how to
testify in court, and cannot represent me in court.
Rule 10-2.1(b) of the Rules Regulating The Florida Bar defines a paralegal as a person who works
under the supervision of a member of The Florida Bar and who performs specifically delegated
substantive legal work for which a member of The Florida Bar is responsible. Only persons who meet the
definition may call themselves paralegals. {Name} ______
, informed me that he/she is not
a paralegal as defined by the rule and cannot call himself/herself a paralegal.
{Name}
, told me that he/she may only type the factual information
provided by me in writing into the blanks on the form. Except for typing, {name} ____
,
may not tell me what to put in the form and may not complete the form for me. However, if using a
form approved by the Supreme Court of Florida, {name} ________________________
,
may ask me factual questions to fill in the blanks on the form and may also tell me how to file the form.
[choose one only]
____ I can read English.
____ I cannot read English, but this disclosure was read to me [fill in both blanks] by
{name} _
in {language} ,which I understand.
Dated:
Signature of Party
Signature of NONLAWYER
Printed Name:
Name of Business:
Address:
Telephone Number:
Instructions for Florida Family Law Rules of Procedure Form 12.900(h), Notice of Related Cases (11/13)
INSTRUCTIONS FOR FLORIDA FAMILY LAW RULES OF PROCEDURE
FORM 12.900(h), NOTICE OF RELATED CASES (11/13)
When should this form be used?
Florida Rule of Judicial Administration 2.545(d) requires the petitioner in a family law case to file
with the court a notice of related cases, if any. Your circuit may also require this form to be filed
even if there are no related cases. A case is considered related if
it involves the same parties, children, or issues and is pending when the family law
case is filed; or
it affects the court’s jurisdiction to proceed; or
an order in the related case may conflict with an order on the same issues in the
new case; or
an order in the new case may conflict with an order in the earlier case.
This form is used to provide the required notice to the court.
This form should be typed or printed in black ink. It must be filed with the clerk of the circuit
court with the initial pleading in the family law case.
What should I do next?
A copy of the form must be served on the presiding judges, either the chief judge or the family
law administrative judge, and all parties in the related cases. You should also keep a copy for
your records. Service must be in accordance with 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 Florida Rule of Judicial
Administration 2.545(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 a Disclosure from Nonlawyer, Florida
Instructions for Florida Family Law Rules of Procedure Form 12.900(h), Notice of Related Cases (11/13)
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.
Florida Family Law Rules of Procedure Form 12.900(h), Notice of Related Cases (11/13)
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA
Case No.:
Division:
_____________________________,
Petitioner,
and
_____________________________,
Respondent.
NOTICE OF RELATED CASES
1. Petitioner submits this Notice of Related Cases as required by Florida Rule of Judicial Administration
2.545(d). A related case may be an open or closed civil, criminal, guardianship, domestic violence,
juvenile delinquency, juvenile dependency, or domestic relations case. A case is “related” to this
family law case if it involves any of the same parties, children, or issues and it is pending at the time
the party files a family case; if it affects the court’s jurisdiction to proceed; if an order in the related
case may conflict with an order on the same issues in the new case; or if an order in the new case
may conflict with an order in the earlier litigation.
[check one only]
___ There are no related cases.
___ The following are the related cases (add additional pages if necessary):
Related Case No. 1
Case Name(s): _____________________________________________________________________
Petitioner ________________________________________________________________________
Respondent _______________________________________________________________________
Case No.: _________________________________ Division: ________________________________
Type of Proceeding: [check all that apply]
____ Dissolution of Marriage ____ Paternity
____ Custody ____ Adoption
____ Child Support ____ Modification/Enforcement/Contempt Proceedings
____ Juvenile Dependency ____ Juvenile Delinquency
____ Termination of Parental Rights ____ Criminal
____ Domestic/Sexual/Dating/Repeat ____ Mental Health
Violence or Stalking Injunctions ____ Other {specify}___________________________
Florida Family Law Rules of Procedure Form 12.900(h), Notice of Related Cases (11/13)
State where case was decided or is pending: ____ Florida ____ Other: {specify} _________________
Name of Court where case was decided or is pending (for example, Fifth Circuit Court, Marion
County, Florida): __________________________________________________________________
Title of last Court Order/Judgment (if any): ______________________________________________
Date of Court Order/Judgment (if any): _________________________________________________
Relationship of cases check all that apply]:
____ pending case involves same parties, children, or issues;
____ may affect court’s jurisdiction;
____ order in related case may conflict with an order in this case;
____ order in this case may conflict with previous order in related case.
Statement as to the relationship of the cases: ____________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Related Case No. 2
Case Name(s): _____________________________________________________________________
Petitioner ________________________________________________________________________
Respondent _______________________________________________________________________
Case No.: _________________________________ Division: ________________________________
Type of Proceeding: [check all that apply]
____ Dissolution of Marriage ____ Paternity
____ Custody ____ Adoption
____ Child Support ____ Modification/Enforcement/Contempt Proceedings
____ Juvenile Dependency ____ Juvenile Delinquency
____ Termination of Parental Rights ____ Criminal
____ Domestic/Sexual/Dating/Repeat ____ Mental Health
Violence or Stalking Injunctions ____Other {specify}__________________________
State where case was decided or is pending: ____ Florida ____ Other: {specify} _________________
Name of Court where case was decided or is pending (for example, Fifth Circuit Court, Marion
County, Florida): __________________________________________________________________
Title of last Court Order/Judgment (if any): ______________________________________________
Date of Court Order/Judgment (if any): _________________________________________________
Relationship of cases check all that apply]:
____ pending case involves same parties, children, or issues;
Florida Family Law Rules of Procedure Form 12.900(h), Notice of Related Cases (11/13)
____ may affect court’s jurisdiction;
____ order in related case may conflict with an order in this case;
____ order in this case may conflict with previous order in related case.
Statement as to the relationship of the cases: ____________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Related Case No. 3
Case Name(s): _____________________________________________________________________
Petitioner ________________________________________________________________________
Respondent _______________________________________________________________________
Case No.: _________________________________ Division: ________________________________
Type of Proceeding: [check all that apply]
____ Dissolution of Marriage ____ Paternity
____ Custody ____ Adoption
____ Child Support ____ Modification/Enforcement/Contempt Proceedings
____ Juvenile Dependency ____ Juvenile Delinquency
____ Termination of Parental Rights ____ Criminal
____ Domestic/Sexual/Dating/Repeat ____ Mental Health
Violence or Stalking Injunctions ____Other {specify} __________________________
State where case was decided or is pending: ____ Florida ____ Other: {specify} _________________
Name of Court where case was decided or is pending (for example, Fifth Circuit Court, Marion
County, Florida): __________________________________________________________________
Title of last Court Order/Judgment (if any): ______________________________________________
Date of Court Order/Judgment (if any): _________________________________________________
Relationship of cases check all that apply]:
____ pending case involves same parties, children, or issues;
____ may affect court’s jurisdiction;
____ order in related case may conflict with an order in this case;
____ order in this case may conflict with previous order in related case.
Statement as to the relationship of the cases: ____________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
2. [check one only]
____ I do not request coordination of litigation in any of the cases listed above.
Florida Family Law Rules of Procedure Form 12.900(h), Notice of Related Cases (11/13)
____ I do request coordination of the following cases: _____________________________________
______________________________________________________________________________
______________________________________________________________________________
3. [check all that apply]
____ Assignment to one judge
____ Coordination of existing cases
will conserve judicial resources and promote an efficient determination of these cases
because:_______________________________________________________________________.
4. The Petitioner acknowledges a continuing duty to inform the court of any cases in this or any other
state that could affect the current proceeding.
Dated: _________________ ________________________________________
Petitioner’s Signature
Printed Name: ______________________________
Address: ________________________________
City, State, Zip: ___________________________
Telephone Number: _______________________
Fax Number: ____________________________
E-mail Address(es):________________________
CERTIFICATE OF SERVICE
I CERTIFY that I delivered a copy of this Notice of Related Cases to the _____________________ County
Sheriff’s Department or a certified process server for service on the Respondent, and [check all used]
( ) e-mailed ( ) mailed ( ) hand delivered, a copy to {name}________________________, who is the
[check all that apply] ( ) judge assigned to new case, ( ) chief judge or family law administrative
judge, ( ) {name}__________________________________ a party to the related case, ( ) {name}
____________________________, a party to the related case on {date} _________________________.
____________________________________
Signature of Petitioner/Attorney for Petitioner
Printed Name:________________________
Address:____________________________
City, State, Zip:________________________
Telephone Number:____________________
Fax Number:__________________________
E-mail Address(es):______________________
Florida Bar Number:_____________________
Florida Family Law Rules of Procedure Form 12.900(h), Notice of Related Cases (11/13)
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} __________, {telephone number} ___________________.
Instructions for Florida Family Law Rules of Procedure Form 12.928, Cover Sheet for Family Court Cases
(11/13)
INSTRUCTIONS FOR FLORIDA FAMILY LAW RULES OF PROCEDURE
FORM 12.928, COVER SHEET FOR FAMILY COURT CASES (11/13)
When should this form be used?
The Cover Sheet for Family Court Cases and the information contained in it neither replace nor
supplement the filing and service of pleadings or other documents as required by law. This form
shall be filed by the petitioner/party opening or reopening a case for the use of the clerk of the
circuit court for the purpose of reporting judicial workload data pursuant to Florida Statutes
section 25.075.
This form should be typed or printed in black ink. The petitioner must file this cover sheet with
the first pleading or motion filed to open or reopen a case in all domestic and juvenile cases.
What should I do next?
Follow these instructions for completing the form:
I. Case Style. Enter the name of the court, the appropriate case number assigned at the time
of filing of the original petition, the name of the judge assigned (if applicable), and the name
(last, first, middle initial) of the petitioner(s) and respondent(s).
II. Type of Action /Proceeding. Place a check beside the proceeding you are initiating. If you are
simultaneously filing more than one type of proceeding against the same opposing party,
such as a modification and an enforcement proceeding, complete a separate cover sheet for
each action being filed.
(A) Initial Action/Petition
(B) Reopening Case. If you check “Reopening Case,” indicate whether you are filing a
modification or supplemental petition or an action for enforcement by placing a check
beside the appropriate action/petition.
1. Modification/Supplemental Petition
2. Motion for Civil Contempt/ Enforcement
3. Other – All reopening actions not involving modification/supplemental petitions or
petition enforcement.
III. Type of Case. Place a check beside the appropriate case. If the case fits more than one
category, select the most definitive. Definitions of the categories are provided below.
(A) Simplified Dissolution of Marriage‐ petitions for the termination of marriage pursuant to
Florida Family Law Rule of Procedure 12.105.
(B) Dissolution of Marriage ‐ petitions for the termination of marriage pursuant to Chapter
61, Florida Statutes, other than simplified dissolution.
(C) Domestic Violence ‐ all matters relating to injunctions for protection against domestic
violence pursuant to section 741.30, Florida Statutes.
Instructions for Florida Family Law Rules of Procedure Form 12.928, Cover Sheet for Family Court Cases
(11/13)
(D) Dating Violence ‐ all matters relating to injunctions for protection against dating
violence pursuant to section 784.046, Florida Statutes.
(E) Repeat Violence ‐ all matters relating to injunctions for protection against repeat
violence pursuant to section 784.046, Florida Statutes.
(F) Sexual Violence ‐ all matters relating to injunctions for protection against sexual
violence pursuant to section 784.046, Florida Statutes.
(G) Stalking-all matters relating to injunctions for protection against stalking pursuant to
section 784.0485, Florida Statutes
(H) Support ‐ IV‐D ‐ all matters relating to child or spousal support in which an application
for assistance has been filed with the Department of Revenue, Child Support
Enforcement under Title IV‐D, Social Security Act, except for such matters relating to
dissolution of marriage petitions (sections 409.2564, 409.2571, and 409.2597, Florida
Statutes), paternity, or UIFSA.
(I) Support‐Non IV‐D ‐ all matters relating to child or spousal support in which an
application for assistance has not been filed under Title IV‐D, Social Security Act.
(J) UIFSA‐ IV‐D ‐ all matters relating to Chapter 88, Florida Statutes, in which an application
for assistance has been filed under Title IV‐D, Social Security Act.
(K) UIFSA ‐ Non IV‐D ‐ all matters relating to Chapter 88, Florida Statutes, in which an
application for assistance has not been filed under Title IV‐D, Social Security Act.
(L) Other Family Court ‐ all matters involving time-sharing and/or parenting plans relating
to minor child(ren), support unconnected with dissolution of marriage, annulment,
delayed birth certificates pursuant to Florida Statutes section 382.0195, expedited
affirmation of parental status pursuant to Florida Statutes section 742.16, termination
of parental rights proceedings pursuant to Florida Statutes section 63.087, declaratory
judgment actions related to premarital, marital, post-marital agreements, or other
matters not included in the categories above.
(M) Adoption Arising Out Of Chapter 63 ‐ all matters relating to adoption pursuant to
Chapter 63, Florida Statutes, excluding any matters arising out of Chapter 39, Florida
Statutes.
(N) Name Change ‐ all matters relating to name change, pursuant to section 68.07, Florida
Statutes.
(O) Paternity/Disestablishment of Paternity – all matters relating to paternity pursuant to
Chapter 742, Florida Statutes.
(P) Juvenile Delinquency ‐ all matters relating to juvenile delinquency pursuant to Chapter
985, Florida Statutes.
(Q) Petition for Dependency ‐ all matters relating to petitions for dependency.
(R) Shelter Petition – all matters relating to shelter petitions pursuant to Chapter 39, Florida
Statutes.
(S) Termination of Parental Rights Arising Out Of Chapter 39 – all matters relating to
termination of parental rights pursuant to Chapter 39, Florida Statutes.
(T) Adoption Arising Out Of Chapter 39 – all matters relating to adoption pursuant to
Chapter 39, Florida Statutes.
(U) CINS/FINS – all matters relating to children in need of services (and families in need of
services) pursuant to Chapter 984, Florida Statutes.
Instructions for Florida Family Law Rules of Procedure Form 12.928, Cover Sheet for Family Court Cases
(11/13)
ATTORNEY OR PARTY SIGNATURE. Sign the Cover Sheet for Family Court Cases. Print legibly the
name of the person signing the Cover Sheet for Family Court Cases. Attorneys must include a
Florida Bar number. Insert the date the Cover Sheet for Family Court Cases is signed. Signature is
a certification that filer has provided accurate information on the Cover Sheet for Family Court
Cases.
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.
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 12.100, Florida Family
Law Rules of Procedure.
Florida Family Law Rules of Procedure Form 12.928, Cover Sheet for Family Court Cases (11/13)
COVER SHEET FOR FAMILY COURT CASES
I. Case Style
IN THE CIRCUIT COURT OF THE ______ JUDICIAL CIRCUIT,
IN AND FOR __________________ COUNTY, FLORIDA
Case No.: ________________
Judge: __________________
_____________________________
Petitioner
and
_____________________________
Respondent
II. Type of Action/Proceeding. Place a check beside the proceeding you are initiating. If you are
simultaneously filing more than one type of proceeding against the same opposing party,
such as a modification and an enforcement proceeding, complete a separate cover sheet for
each action being filed. If you are reopening a case, choose one of the three options below
it.
(A) ____ Initial Action/Petition
(B) ____ Reopening Case
1. ____ Modification/Supplemental Petition
2. ____ Motion for Civil Contempt/Enforcement
3. ____ Other
III. Type of Case. If the case fits more than one type of case, select the most definitive.
(A) ____ Simplified Dissolution of Marriage
(B) ____ Dissolution of Marriage
(C) ____ Domestic Violence
(D) ____ Dating Violence
(E) ____ Repeat Violence
(F) ____ Sexual Violence
(G) ____ Stalking
(H) ____ Support IV‐D (Department of Revenue, Child Support Enforcement)
(I) ____ Support Non‐IV‐D (not Department of Revenue, Child Support Enforcement)
(J) ____ UIFSA IV‐D (Department of Revenue, Child Support Enforcement)
(K) ____ UIFSA Non‐IV‐D (not Department of Revenue, Child Support Enforcement)
(L) ____ Other Family Court
(M) ____ Adoption Arising Out Of Chapter 63
(N) ____ Name Change
Florida Family Law Rules of Procedure Form 12.928, Cover Sheet for Family Court Cases (11/13)
(O) ____ Paternity/Disestablishment of Paternity
(P) ____ Juvenile Delinquency
(Q) ____ Petition for Dependency
(R) ____ Shelter Petition
(S) ____ Termination of Parental Rights Arising Out Of Chapter 39
(T) ____ Adoption Arising Out Of Chapter 39
(U) ____ CINS/FINS
IV. Rule of Judicial Administration 2.545(d) requires that a Notice of Related Cases Form, Family
Law Form 12.900(h), be filed with the initial pleading/petition by the filing attorney or self-
represented litigant in order to notify the court of related cases. Is Form 12.900(h) being
filed with this Cover Sheet for Family Court Cases and initial pleading/petition?
____ No, to the best of my knowledge, no related cases exist.
____ Yes, all related cases are listed on Family Law Form 12.900(h).
ATTORNEY OR PARTY SIGNATURE
I CERTIFY that the information I have provided in this cover sheet is accurate to the best
of my knowledge and belief.
Signature________________________________________ FL Bar No.: _____________________
Attorney or party (Bar number,if attorney)
________________________________________ __________________________
(Type or print name) (E-mail Address(es))
____________________________
Date
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}______ , {telephone number }__________________.
Instructions for Florida Supreme Court Approved Family Law Form 12.904(a)(2), Petition for Support and
Parenting Plan Unconnected with Dissolution of Marriage (02/18)
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY
LAW FORM 12.904(a)(2),
PETITION FOR SUPPORT AND PARENTING PLAN UNCONNECTED
WITH DISSOLUTION OF MARRIAGE WITH DEPENDENT OR MINOR
CHILD(REN)
(02/18)
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. It may also be used to
establish a Parenting Plan with a time-sharing schedule. 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 or debts. It only deals with alimony, child
support, and Parenting Plans.
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
this petition, you are also 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. 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
Memorandum for Certificate of Military Service, Florida Supreme Court Approved Family Law
Instructions for Florida Supreme Court Approved Family Law Form 12.904(a)(2), Petition for Support and
Parenting Plan Unconnected with Dissolution of Marriage (02/18)
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:
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 contact 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 contact 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?
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 61.09, Florida Statutes.
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
Instructions for Florida Supreme Court Approved Family Law Form 12.904(a)(2), Petition for Support and
Parenting Plan Unconnected with Dissolution of Marriage (02/18)
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.
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:
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 your
spouse’s income, you may file this worksheet after your spouse’s financial affidavit has been
served on you.)
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.
Alimony. Alimony may be awarded to a spouse if the judge finds that one spouse 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-
Instructions for Florida Supreme Court Approved Family Law Form 12.904(a)(2), Petition for Support and
Parenting Plan Unconnected with Dissolution of Marriage (02/18)
the-gap alimony, durational alimony, and/or rehabilitative alimony. If alimony is awarded, the
judge may order periodic payments, payments in lump sum, or both.
Child Support. Both parents are required to provide financial support for their minor or
dependent children; however, the court may order one parent to pay child support 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.
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).
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
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
Instructions for Florida Supreme Court Approved Family Law Form 12.904(a)(2), Petition for Support and
Parenting Plan Unconnected with Dissolution of Marriage (02/18)
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.
Florida Supreme Court Approved Family Law Form 12.904(a)(2), Petition for Support and Parenting Plan
Unconnected with Dissolution of Marriage with Dependent or Minor Child(ren) (02/18)
IN THE CIRCUIT COURT OF THE _____________________ JUDICIAL CIRCUIT,
IN AND FOR ______________________________ COUNTY, FLORIDA
In re: the Marriage of: Case No: ________________________
Division: ________________________
_________________________________,
Petitioner,
and
_________________________________,
Respondent.
PETITION FOR SUPPORT AND PARENTING PLAN UNCONNECTED
WITH DISSOLUTION OF MARRIAGE WITH DEPENDENT OR MINOR
CHILD(REN)
I, {full legal name} ______________________________________, the Petitioner, being sworn,
certify that the following statements are true:
1. JURISDICTION
_____ Petitioner _____ Respondent ______ Both live in Florida at the filing of this Petition for
Support and Parenting Plan Unconnected with Dissolution of Marriage, which is filed pursuant to
section 61.09, Florida Statutes.
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. MINOR CHILD(REN)
[Indicate all that apply]
a. _____Petitioner is pregnant. The baby is due on: {date} ____________
b. _____Respondent is pregnant. The baby is due on: {date}_____________________________
c.____ The minor (under 18) child(ren) common to both parties, conceived or born during the
marriage, are:
Name Birth date
___________
____________
Florida Supreme Court Approved Family Law Form 12.904(a)(2), Petition for Support and Parenting Plan
Unconnected with Dissolution of Marriage with Dependent or Minor Child(ren) (02/18)
___________
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. _____Petitioner does not request spousal support (alimony) from Respondent at this time.
OR
2. _____ Respondent has the ability to contribute to Petitioner’s support and has failed to do so.
Petitioner requests that the Court order Respondent to pay spousal support (alimony) to
Petitioner, who claims that he or she has an actual need for the support that he or she is
requesting. Spousal support (alimony) is requested in the amount of $____________ every _____
week _____ other week _____ month, or ______other__________________________, beginning
{date}_________________, and continuing until {date or event} _________________________.
Explain why the Court should order Respondent to pay and any specific request(s) for type of
alimony (temporary, permanent, rehabilitative, bridge-the-gap, durational, and/or lump sum):
______________________________________________________________________________
.
3. _____Other provisions relating to alimony including any tax treatment and consequences:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Florida Supreme Court Approved Family Law Form 12.904(a)(2), Petition for Support and Parenting Plan
Unconnected with Dissolution of Marriage with Dependent or Minor Child(ren) (02/18)
4. Petitioner requests life insurance on the other spouse’s life, provided by that spouse, to secure
such support.
SECTION II. PARENTING PLAN ESTABLISHING PARENTAL RESPONSIBILITY AND TIME-SHARING
1. The minor child(ren) currently reside(s) with _____ Petitioner _____ Respondent _____ 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 parents;
b. _____ awarded solely to _____ Petitioner _____ Respondent. 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). For purposes of a Parenting Plan, the Petitioner will be referred
to as {name or designation}____________________, and the Respondent will be referred to as
{name or designation}_________________________________. 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. _____Each child will have time-sharing with both parents as follows: __________________
_____________________________________________________________________
_________________________________________________________________________
(_____ Indicate if a separate sheet is attached.)
c. _____ The court should establish a Parenting Plan with the following provisions for:
{Insert name or designation of the appropriate parent in the space provided}
_____ No time-sharing for Parent ________________________
_____ Limited time-sharing with Parent ___________________
_____ Supervised Time-Sharing for Parent ______________Parent________________;
_____ Supervised or third-party exchange of the child(ren).
_____ Explain: __________________________________________________________
_______________________________________________________________________
_______________________________________________________________________.
4. Explain why this request is in the best interests of the child(ren): _________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Florida Supreme Court Approved Family Law Form 12.904(a)(2), Petition for Support and Parenting Plan
Unconnected with Dissolution of Marriage with Dependent or Minor Child(ren) (02/18)
SECTION III. CHILD SUPPORT
1. Respondent has the ability to contribute to the support of his or her minor child(ren) and has failed
to do so. Based upon the time-sharing schedule, the Petitioner is entitled to child support.
[Indicate all that apply]
2.______ Petitioner requests that the Court award child support as determined by Florida’s child
support guidelines, section 61.30, Florida Statutes.
3. _____Petitioner requests that the Court award child support to be paid beyond the age of 18 years
by Respondent 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._____ Petitioner requests that medical/dental insurance for the minor child(ren) be provided by:
[Choose only one]
a. _____ Petitioner.
b. _____ Respondent.
5._____ Petitioner requests that uninsured medical/dental expenses for the
child(ren) be paid: [Choose only one]
a. _____ by Petitioner
b. _____ by Respondent
c. _____ equally (each spouse pays 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. _____ Petitioner requests that life insurance to secure child support be provided by:
______ Respondent _____ both spouses.
SECTION IV. OTHER RELIEF
Florida Supreme Court Approved Family Law Form 12.904(a)(2), Petition for Support and Parenting Plan
Unconnected with Dissolution of Marriage with Dependent or Minor Child(ren) (02/18)
SECTION V. REQUEST
(This section summarizes what you are asking the Court to include in the order for support.)
Petitioner requests that the Court enter an order:
{Indicate all that apply}
1. ____ awarding spousal support (alimony) as requested in Section I of this petition;
2. ____ adopting or establishing a Parenting Plan containing provisions for parental responsibility and
time-sharing for the dependent or minor child(ren), as requested in Section II of this petition;
3. ____ establishing child support for the minor child(ren), as requested in Section III of this petition;
4.____ awarding other relief as requested in Section IV of this petition; and any other items 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 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 12.904(a)(2), Petition for Support and Parenting Plan
Unconnected with Dissolution of Marriage with Dependent or Minor Child(ren) (02/18)
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} _______________.
INSTRUCTIONS FOR THE
SUPPLEMENTAL INFORMATION REGARDING PARTIES FORM
The Supplemental Information Regarding Parties form will aid the Court and the Clerk of
the Circuit Court in identifying related cases. This will help ensure that your related cases are
heard before the same judge at the same time and reduce the number of times you have to appear
in court.
When should this form be filed?
The Supplemental Information Regarding Parties form only needs to be completed and filed in
civil domestic violence cases, dissolution cases, paternity cases, or child support actions.
Who should complete and file the form?
The Supplemental Information Regarding Parties form must be completed and filed by the
Petitioner with the case-initiating documents. The Respondent may choose to complete and file
the form at a later date.
How should the form be completed?
The person completing the Supplemental Information Regarding Parties form should answer the
questions relating to them thoroughly and accurately. The person should also make a good faith
effort to complete the portion of the form relating to the opposing party.
What should I do next?
The Supplemental Information Regarding Parties form must be served on the opposing party.
Service must be in accordance with Florida Rule of Judicial Administration 2.516, except that
the Petitioner may choose to serve the form along with the case-initiating documents.
IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL CIRCUIT,
IN AND FOR PASCO/PINELLAS COUNTY, FLORIDA
_____________________________
Petitioner, Case No.: ___________________
and Section: ___________________
______________________________
Respondent.
_______________________________/
SUPPLEMENTAL INFORMATION REGARDING PARTIES
The information provided in this form will assist the court and the Clerk of the Circuit
Court in identification of related cases pursuant to Florida Rule of Judicial Administration 2.545.
1. Petitioner’s Information:
a. Full Legal Name: _____________________________________________
b. Previous Names: _____________________________________________
(Maiden names, previous married or legal names, aliases (AKA’s))
c. Date of Birth: __________________ PID/SPN:
d. Information on Children:
i. __Petitioner does not have any minor children.
ii. __Petitioner has a minor child(ren) in common with Respondent.
(If you have checked this line, please complete page 2.)
iii. __Petitioner has a minor child(ren) NOT in common with Respondent.
(If you have checked this line, please complete page 3.)
2. Respondent’s Information:
a. Full Legal Name: _____________________________________________
b. Previous Names: _____________________________________________
(Maiden names, previous married or legal names, aliases (AKA’s))
c. Date of Birth: __________________ PID/SPN:
d. Information on Children:
i. __Respondent does not have any minor children.
ii. __Respondent has a minor child(ren) in common with Petitioner.
(If you have checked this line, please complete page 2.)
iii. __Respondent has a minor child(ren) NOT in common with Petitioner.
(If you have checked this line, please complete page 3.)
Case Number:
Section:
Sixth Circuit Administrative Order 2016-030 - Attachment A
Page 2 of 4
3. Minor Child(ren) In Common: The number of minor children In Common is _____.
Information about child #1: Date of Birth: _________________ Sex: __________
Child’s Full Legal Name: _______________________________________________
Has the child’s name ever been changed? ___ Yes ___ No
If yes, list the child’s name before it was changed: _________________________
Information about child #2: Date of Birth: _________________ Sex: __________
Child’s Full Legal Name: _______________________________________________
Has the child’s name ever been changed? ___ Yes ___ No
If yes, list the child’s name before it was changed: _________________________
Information about child #3: Date of Birth: _________________ Sex: __________
Child’s Full Legal Name: _______________________________________________
Has the child’s name ever been changed? ___ Yes ___ No
If yes, list the child’s name before it was changed: _________________________
Information about child #4: Date of Birth: _________________ Sex: __________
Child’s Full Legal Name: _______________________________________________
Has the child’s name ever been changed? ___ Yes ___ No
If yes, list the child’s name before it was changed: _________________________
Information about child #5: Date of Birth: _________________ Sex: __________
Child’s Full Legal Name: _______________________________________________
Has the child’s name ever been changed? ___ Yes ___ No
If yes, list the child’s name before it was changed: _________________________
Information about child #6: Date of Birth: _________________ Sex: __________
Child’s Full Legal Name: _______________________________________________
Has the child’s name ever been changed? ___ Yes ___ No
If yes, list the child’s name before it was changed: _________________________
If additional space is needed, please use another sheet of paper and attach it to this form.
Case Number:
Section:
Sixth Circuit Administrative Order 2016-030 - Attachment A
Page 3 of 4
4. Minor Child(ren) NOT In Common: The number of minor children NOT In
Common is _____.
Information about child #1: Date of Birth: _________________ Sex: __________
Child’s Full Legal Name: _______________________________________________
Has the child’s name ever been changed? ___ Yes ___ No
If yes, list the child’s name before it was changed: _________________________
This is the child of (please check one): Petitioner Respondent
Information about child #2: Date of Birth: _________________ Sex: __________
Child’s Full Legal Name: _______________________________________________
Has the child’s name ever been changed? ___ Yes ___ No
If yes, list the child’s name before it was changed: _________________________
This is the child of (please check one): Petitioner Respondent
Information about child #3: Date of Birth: _________________ Sex: __________
Child’s Full Legal Name: _______________________________________________
Has the child’s name ever been changed? ___ Yes ___ No
If yes, list the child’s name before it was changed: _________________________
This is the child of (please check one): Petitioner Respondent
Information about child #4: Date of Birth: _________________ Sex: __________
Child’s Full Legal Name: _______________________________________________
Has the child’s name ever been changed? ___ Yes ___ No
If yes, list the child’s name before it was changed: _________________________
This is the child of (please check one): Petitioner Respondent
Information about child #5: Date of Birth: _________________ Sex: __________
Child’s Full Legal Name: _______________________________________________
Has the child’s name ever been changed? ___ Yes ___ No
If yes, list the child’s name before it was changed: _________________________
This is the child of (please check one): Petitioner Respondent
Information about child #6: Date of Birth: _________________ Sex: __________
Child’s Full Legal Name: _______________________________________________
Has the child’s name ever been changed? ___ Yes ___ No
If yes, list the child’s name before it was changed: _________________________
This is the child of (please check one): Petitioner Respondent
If additional space is needed, please use another sheet of paper and attach it to this form.
Case Number:
Section:
Sixth Circuit Administrative Order 2016-030 - Attachment A
Page 4 of 4
5. The undersigned party acknowledges a continuing duty to inform the court of any cases
in this or any other state that could affect the current proceeding.
Dated: _________________ ____________________________________
Party’s Signature
Printed Name: __________________________
Address: _______________________________
City, State, Zip: _________________________
Telephone Number: ______________________
Fax Number: ___________________________
E-mail Address(es): ______________________
If a nonlawyer helped you fill out this form, he/she must fill in ALL the blanks below:
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} _____, {telephone number} _____________________
Instructions for Florida Supreme Court Approved Family Law Form 12.902(j), Notice of Social Security Number
(11/15)
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.902(j),
NOTICE OF SOCIAL SECURITY NUMBER (11/15)
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
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.
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 12.902(j), Notice of Social Security Number
(11/15)
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...
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).
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(j), Notice of Social Security Number (11/15)
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.}
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 (11/15)
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} _____________.
Instructions for Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody Jurisdiction
and Enforcement Act (UCCJEA) Affidavit (02/18)
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.902(d)
UNIFORM CHILD CUSTODY JURISDICTION AND ENFORCEMENT ACT
(UCCJEA) AFFIDAVIT
(02/18)
When should this form be used?
This form should be used in any case involving parental responsibility for, custody of, or time-sharing or
visitation with, any minor child(ren). This affidavit is required even if the parental responsibility for,
custody of, or time-sharing or visitation with, the minor child(ren) is 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 it 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
Instructions for Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody Jurisdiction
and Enforcement Act (UCCJEA) Affidavit (02/18)
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.
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...
With this form, you must also file a Notice of Confidential Information within Court Filing, Florida Rules
of Judicial Administration Appendix to Rule 2.420 Form.
Effective October 1, 2008, terms such as custodial parent, noncustodial parent, primary residential
parent, secondary residential parent, and visitation were removed from Chapter 61, Florida Statutes;
however, because the UCCJEA uses the terms, custody and visitation, they are included in this form.
Parents must 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.
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 (02/18)
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 (02/18)
____/____
____/____
* 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
____/____
____/____
____/____
____/____
____/____
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 (02/18)
____/____
____/____
____/____
____/____
____/____
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, jurisdiction, or country, concerning parental
responsibility for, custody of, or time-sharing or visitation 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, jurisdiction, or country, concerning parental
responsibility for, custody of, or time-sharing or visitation 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 parental responsibility, custody, time-sharing, or
visitation proceeding pending in a court of this or any other state, jurisdiction, or country
concerning a child subject to this proceeding.
______ I HAVE THE FOLLOWING INFORMATION concerning a parental responsibility, custody,
time-sharing, or visitation 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:
a. Name of each child involved in said litigation:
b. Type of proceeding:
c. Court and state:
d. Date of court order or judgment (if any):
e. Case Number: _______________________________________________________________
Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody Jurisdiction and Enforcement
Act (UCCJEA) Affidavit (02/18)
4. Persons not a party to this proceeding:
[Choose only one]
______ I DO NOT KNOW OF ANY PERSON in this or any other state, jurisdiction, or country, who
is not a party to this proceeding and who has physical custody or claims to have parental
responsibility for, custody of, or time-sharing or visitation 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 parental responsibility for, custody of, , or time-
sharing or visitation with respect to any child subject to this proceeding:
a. Name and address of person:
_____ has physical custody
_____ claims parental responsibility or custody rights
_____ claims time-sharing or visitation
Name of each child:
Relationship to child, if any:________________________________________________________
b. Name and address of person:
_____ has physical custody
_____ claims parental responsibility or custody rights
_____ claims time-sharing or visitation
Name of each child:
Relationship to child, if any:________________________________________________________
c. Name and address of person:
_____ has physical custody
_____ claims parental responsibility or custody rights
_____claims time-sharing or visitation
Name of each child:
Relationship to child, if any:________________________________________________________
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 other state, jurisdiction, or country..
_____ 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): ___________________________________________
Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody Jurisdiction and Enforcement
Act (UCCJEA) Affidavit (02/18)
e. Amount of child support ordered to be paid and by whom:
6. I acknowledge that I have a continuing duty to advise this Court of any parental responsibility,
custody, time-sharing or visitation , 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.
7. A completed Notice of Confidential Information within Court Filing, Florida Rules of Judicial
Administration Appendix to Rule 2.420 Form, is filed with this Affidavit.
I certify that a copy of this document was ( ) e-served ( ) 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:
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 ________________________
Sworn to or affirmed and signed before me on by .
NOTARY PUBLIC or DEPUTY CLERK
Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody Jurisdiction and Enforcement
Act (UCCJEA) Affidavit (02/18)
__________________________________________________
[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}________________.
Instructions to Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form)
(01/15)
INSTRUCTIONS FOR FLORIDA FAMILY LAW RULES OF PROCEDURE FORM
12.902(b), FAMILY LAW FINANCIAL AFFIDAVIT (SHORT FORM) (01/15)
When should this form be used?
This form should be used when you are involved in a family law case which requires a financial affidavit
and your individual gross income is UNDER $50,000 per year unless:
(1) You are filing a simplified dissolution of marriage under rule 12.105 and both parties have
waived the filing of a financial affidavit;
(2) You have no minor children, no support issues, and have filed a written settlement agreement
disposing of all financial issues; or
(3) The court lacks jurisdiction to determine any financial issues.
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.
What should I do next?
A copy of this form must be served on the other party in your case within 45 days of being served with
the petition, if it is not served on him or her with your initial papers. Service must be in accordance with
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 Florida Family Law Rule of Procedure 12.285.
Special notes...
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 Request for
Confidential Filing of Address, Florida Supreme Court Approved Family Law Form 12.980(h).
The affidavit must be completed using monthly income and expense amounts. If you are paid or your
bills are due on a schedule which is not monthly, you must convert those amounts. Hints are provided
below for making these conversions.
Instructions to Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form)
(01/15)
Hourly - If you are paid by the hour, you may convert your income to monthly as follows:
Hourly amount x Hours worked per week = Weekly amount
Weekly amount x 52 Weeks per year = Yearly amount
Yearly amount ÷ 12 Months per year = Monthly Amount
Daily - If you are paid by the day, you may convert your income to monthly as follows:
Daily amount x Days worked per week = Weekly amount
Weekly amount x 52 Weeks per year = Yearly amount
Yearly amount ÷ 12 Months per year = Monthly Amount
Weekly - If you are paid by the week, you may convert your income to monthly as follows:
Weekly amount x 52 Weeks per year = Yearly amount
Yearly amount ÷ 12 Months per year = Monthly Amount
Bi-weekly - If you are paid every two weeks, you may convert your income to monthly as follows:
Bi-weekly amount x 26 = Yearly amount
Yearly amount ÷ 12 Months per year = Monthly Amount
Semi-monthly - If you are paid twice per month, you may convert your income to monthly as follows:
Semi-monthly amount x 2 = Monthly Amount
Expenses may be converted in the same manner.
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 Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form) (01/15)
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA
Case No.: ______________________
Division: _______________________
,
Petitioner,
and
,
Respondent.
FAMILY LAW FINANCIAL AFFIDAVIT (SHORT FORM)
(Under $50,000 Individual Gross Annual Income)
I, {full legal name} , being sworn, certify that the following
information is true:
My Occupation: Employed by: ___________________________
Business Address: ________________________________________________________________
Pay rate: $ ( ) every week ( ) every other week ( ) twice a month ( ) monthly
( ) other: ____________
___ Check here if unemployed and explain on a separate sheet your efforts to find employment.
SECTION I. PRESENT MONTHLY GROSS INCOME:
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 gross salary or wages
2. ______ Monthly bonuses, commissions, allowances, overtime, tips, and similar payments
3. _______Monthly business income from sources such as self-employment, partnerships, close
corporations, and/or independent contracts (gross receipts minus ordinary and necessary
expenses required to produce income) (Attach sheet itemizing such income and expenses.)
4. _______Monthly disability benefits/SSI
5. _______Monthly Workers’ Compensation
6. _______Monthly Unemployment Compensation
7. _______Monthly pension, retirement, or annuity payments
8. _______Monthly Social Security benefits
9. ______ Monthly alimony actually received (Add 9a and 9b)
9a. From this case: $ _______
9b. From other case(s): _______
10. _______ Monthly interest and dividends
11. _______Monthly rental income (gross receipts minus ordinary and necessary expenses
Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form)(01/15)
required to produce income) (Attach sheet itemizing such income and expense items.)
12. _______ Monthly income from royalties, trusts, or estates
13. _______ Monthly reimbursed expenses and in-kind payments to the extent that they
reduce personal living expenses
14. _______ Monthly gains derived from dealing in property (not including nonrecurring gains)
15. _______ Any other income of a recurring nature (list source) _________________________
16. __________________________________________________________________________
17. $ _______ TOTAL PRESENT MONTHLY GROSS INCOME (Add lines 1–16)
PRESENT MONTHLY DEDUCTIONS:
18. $______Monthly federal, state, and local income tax (corrected for filing status and allowable
dependents and income tax liabilities)
a. Filing Status ____________
b. Number of dependents claimed _______
19. _______ Monthly FICA or self-employment taxes
20. _______ Monthly Medicare payments
21. _______ Monthly mandatory union dues
22. _______ Monthly mandatory retirement payments
23. _______ Monthly health insurance payments (including dental insurance), excluding portion
paid for any minor children of this relationship
24. _______ Monthly court-ordered child support actually paid for children from another
relationship
25. _______Monthly court-ordered alimony actually paid (Add 25a and 25b)
25a. from this case: $ _______
25b. from other case(s):$ _______
26. $_______ TOTAL DEDUCTIONS ALLOWABLE UNDER SECTION 61.30, FLORIDA STATUTES
(Add lines 18 through 25).
27. $_______ PRESENT NET MONTHLY INCOME (Subtract line 26 from line 17)
Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form) (01/15)
SECTION II. AVERAGE MONTHLY EXPENSES
Proposed/Estimated Expenses. If this is a dissolution of marriage case and your expenses as listed
below do not reflect what you actually pay currently, you should write “estimate” next to each amount
that is estimated.
A. HOUSEHOLD:
Mortgage or rent $ _______
Property taxes $_______
Utilities $_______
Telephone $ _______
Food $ _______
Meals outside home $_______
Maintenance/Repairs $ _______
Other: __________ $_______
B. AUTOMOBILE
Gasoline $ _______
Repairs $_______
Insurance $_______
C. CHILD(REN)’S EXPENSES
Day care $ _______
Lunch money $_______
Clothing $ _______
Grooming $_______
Gifts for holidays $ _______
Medical/Dental (uninsured) $ _______
Other: ______________ $ _______
D. INSURANCE
Medical/Dental (if not listed on
lines 23 or 45) $ _______
Child(ren)’s medical/dental $ _______
Life $ _______
Other: $ _______
E. OTHER EXPENSES NOT LISTED ABOVE
Clothing $ _______
Medical/Dental (uninsured) $_______
Grooming $ _______
Entertainment $_______
Gifts $_______
Religious organizations $_______
Miscellaneous $_______
Other: ______________ $ _______
____________________ $_______
____________________ $_______
____________________ $_______
____________________ $_______
____________________ $_______
F. PAYMENTS TO CREDITORS
CREDITOR: MONTHLY
PAYMENT
____________________ $_______
____________________ $_______
____________________ $_______
____________________ $_______
____________________ $_______
____________________ $_______
____________________ $_______
____________________ $_______
____________________ $_______
____________________ $_______
____________________ $_______
Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form)
(01/15)
28. $_______ TOTAL MONTHLY EXPENSES (add ALL monthly amounts in A through F above)
SUMMARY
29. $_______ TOTAL PRESENT MONTHLY NET INCOME (from line 27 of SECTION I. INCOME)
30. $_______ TOTAL MONTHLY EXPENSES (from line 28 above)
31. $_______ SURPLUS (If line 29 is more than line 30, subtract line 30 from line 29. This is the amount
of your surplus. Enter that amount here.)
32. ($_______) (DEFICIT) (If line 30 is more than line 29, subtract line 29 from line 30. This is the amount
of your deficit. Enter that amount here.)
SECTION III. ASSETS AND LIABILITIES
Use the nonmarital column only if this is a petition for dissolution of marriage and you believe an item
is “nonmarital,” meaning it belongs to only one of you and should not be divided. You should indicate
to whom you believe the item(s) or debt belongs. (Typically, you will only use this column if
property/debt was owned/owed by one spouse before the marriage. See the “General Information for
Self-Represented Litigants” found at the beginning of these forms and section 61.075(1), Florida
Statutes, for definitions of “marital” and “nonmarital” assets and liabilities.)
A. ASSETS:
DESCRIPTION OF ITEM(S). List a description of each separate item
owned by you (and/or your spouse, if this is a petition for dissolution
of marriage). LIST ONLY LAST 4 DIGITS OF ACCOUNT NUMBERS. Check
the line next to any asset(s) which you are requesting the judge
award to you.
Current
Fair
Market
Value
Nonmarital
(check correct
column)
husband
wife
Cash (on hand)
$
Cash (in banks or credit unions)
Stocks, Bonds, Notes
Real estate: (Home)
(Other)
Automobiles
Other personal property
Retirement plans (Profit Sharing, Pension, IRA, 401(k)s, etc.)
Other
____Check here if additional pages are attached.
Total Assets (add next column)
$
Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form)
(01/15)
B. LIABILITIES:
DESCRIPTION OF ITEM(S). List a description of each separate debt
owed by you (and/or your spouse, if this is a petition for dissolution
of marriage). LIST ONLY LAST 4 DIGITS OF ACCOUNT NUMBERS. Check
the line next to any debt(s) for which you believe you should be
responsible.
Current
Amount
Owed
Nonmarital
(check correct
column)
husband
wife
Mortgages on real estate: First mortgage on home
$
Second mortgage on home
Other mortgages
Auto loans
Charge/credit card accounts
Other
____Check here if additional pages are attached.
Total Debts (add next column)
$
C. CONTINGENT ASSETS AND LIABILITIES:
INSTRUCTIONS: If you have any POSSIBLE assets (income potential, accrued vacation or sick leave,
bonus, inheritance, etc.) or POSSIBLE liabilities (possible lawsuits, future unpaid taxes, contingent tax
liabilities, debts assumed by another), you must list them here.
Contingent Assets
Check the line next to any contingent asset(s) which you are requesting the
judge award to you.
Possible
Value
Nonmarital
(check correct
column)
husband
wife
$
Total Contingent Assets
$
Contingent Liabilities
Check the line next to any contingent debt(s) for which you believe you
should be responsible.
Possible
Amount
Owed
Nonmarital
(check correct
column)
husband
wife
$
Total Contingent Liabilities
$
Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form)
(01/15)
SECTION IV. CHILD SUPPORT GUIDELINES WORKSHEET
(Florida Family Law Rules of Procedure Form 12.902(e), Child Support Guidelines Worksheet, MUST be
filed with the court at or prior to a hearing to establish or modify child support. This requirement cannot
be waived by the parties.)
[Check one only]
____ A Child Support Guidelines Worksheet IS or WILL BE filed in this case. This case involves the
establishment or modification of child support.
____ A Child Support Guidelines Worksheet IS NOT being filed in this case. The establishment or
modification of child support is not an issue in this case.
I certify that a copy of this document was [check all used]: ( ) 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: _________________________
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: ______________________________
Fax 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
Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form)
(01/15)
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} ________ {telephone number} .
Instructions for Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (Long Form)
(01/15)
INSTRUCTIONS FOR FLORIDA FAMILY LAW RULE OF PROCEDURE FORM
12.902(c), FAMILY LAW FINANCIAL AFFIDAVIT (LONG FORM)(01/15)
When should this form be used?
This form should be used when you are involved in a family law case which requires a financial affidavit
and your individual gross income is $50,000 OR MORE per year unless:
(1) You are filing a simplified dissolution of marriage under rule 12.105 and both parties have
waived the filing of financial affidavits;
(2) you have no minor children, no support issues, and have filed a written settlement agreement
disposing of all financial issues; or
(3) the court lacks jurisdiction to determine any financial issues.
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 served on the other party in your case within 45 days of being served with
the petition, if it is not served on him or her with your initial papers. Service must be in accordance
with 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 Florida Family Law Rule of Procedure 12.285.
Special notes...
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 Request for
Confidential Filing of Address, Florida Supreme Court Approved Family Law Form 12.980(h).
The affidavit must be completed using monthly income and expense amounts. If you are paid or your
bills are due on a schedule which is not monthly, you must convert those amounts. Hints are provided
below for making these conversions.
Instructions for Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (Long Form)
(01/15)
Hourly - If you are paid by the hour, you may convert your income to monthly as follows:
Hourly amount x Hours worked per week = Weekly amount
Weekly amount x 52 Weeks per year = Yearly amount
Yearly amount ÷ 12 Months per year = Monthly Amount
Daily - If you are paid by the day, you may convert your income to monthly as follows:
Daily amount x Days worked per week = Weekly amount
Weekly amount x 52 Weeks per year = Yearly amount
Yearly amount ÷ 12 Months per year = Monthly Amount
Weekly - If you are paid by the week, you may convert your income to monthly as follows:
Weekly amount x 52 Weeks per year = Yearly amount
Yearly amount ÷ 12 Months per year = Monthly Amount
Bi-weekly - If you are paid every two weeks, you may convert your income to monthly as
follows:
Bi-weekly amount x 26 = Yearly amount
Yearly amount ÷ 12 Months per year = Monthly Amount
Semi-monthly - If you are paid twice per month, you may convert your income to monthly as
follows:
Semi-monthly amount x 2 = Monthly Amount
Expenses may be converted in the same manner.
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 Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (Long Form) (01/15)
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA
Case No.:
Division:
,
Petitioner,
and
,
Respondent.
FAMILY LAW FINANCIAL AFFIDAVIT (LONG FORM)
($50,000 or more Individual Gross Annual Income)
I, {full legal name} , being sworn, certify
that the following information is true:
SECTION I. INCOME
1. My age is: ___________________
2. My occupation is: ________________________________________________________________
3. I am currently
[Check all that apply]
a. ____ Unemployed
Describe your efforts to find employment, how soon you expect to be employed, and the pay
you expect to receive: __________________________________________________________
____________________________________________________________________________
b. ____ Employed by: ____________________________________________________________
Address: ____________________________________________________________________
City, State, Zip code: ________________________________ Telephone Number: _________
Pay rate: $ ______ ( ) every week ( ) every other week ( ) twice a month
( ) monthly ( ) other: ________________________________________________________
If you are expecting to become unemployed or change jobs soon, describe the change you
expect and why and how it will affect your income: _________________________________
___________________________________________________________________________
___________________________________________________________________________.
____ Check here if you currently have more than one job. List the information above for the
second job(s) on a separate sheet and attach it to this affidavit.
Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (Long Form) (01/15)
c. _____ Retired. Date of retirement: _______________________________________________
Employer from whom retired: ___________________________________________________
Address: _____________________________________________________________________
City, State, Zip code: _______________________________ Telephone Number: __________
LAST YEAR’S GROSS INCOME: Your Income Other Party’s Income (if known)
YEAR_____ $ _______ $ _______
PRESENT MONTHLY GROSS INCOME:
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 gross salary or wages
2. _______ Monthly bonuses, commissions, allowances, overtime, tips, and similar payments
3. _______ Monthly business income from sources such as self-employment, partnerships, close
corporations, and/or independent contracts (Gross receipts minus ordinary and necessary
expenses required to produce income.)(Attach sheet itemizing such income and expenses.)
4. _______ Monthly disability benefits/SSI
5. _______ Monthly Workers’ Compensation
6. _______ Monthly Unemployment Compensation
7. _______ Monthly pension, retirement, or annuity payments
8. _______ Monthly Social Security benefits
9. _______ Monthly alimony actually received (Add 9a and 9b)
9a. From this case: $________
9b. From other case(s): ________
10. _______ Monthly interest and dividends
11. _______ Monthly rental income (gross receipts minus ordinary and necessary expenses required to
produce income) (Attach sheet itemizing such income and expense items.)
12. _______ Monthly income from royalties, trusts, or estates
13. _______ Monthly reimbursed expenses and in-kind payments to the extent that they reduce
personal living expenses (Attach sheet itemizing each item and amount.)
14. _______ Monthly gains derived from dealing in property (not including nonrecurring gains)
Any other income of a recurring nature (identify source)
15. _______________________________________________________________________________
16. _______________________________________________________________________________
17. $_________ TOTAL PRESENT MONTHLY GROSS INCOME (Add lines 1 through 16).
PRESENT MONTHLY DEDUCTIONS:
All amounts must be MONTHLY. See the instructions with this form to figure out money amounts for
anything that is NOT paid monthly.
18. $_______ Monthly federal, state, and local income tax (corrected for filing status and allowable
dependents and income tax liabilities)
a. Filing Status
b. Number of dependents claimed
19. _______ Monthly FICA or self-employment taxes
20. _______ Monthly Medicare payments
Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (Long Form) (01/15)
21. _______ Monthly mandatory union dues
22. _______ Monthly mandatory retirement payments
23. _______ Monthly health insurance payments (including dental insurance), excluding portion paid for
any minor children of this relationship
24. _______ Monthly court-ordered child support actually paid for children from another relationship
25. _______ Monthly court-ordered alimony actually paid (Add 25a and 25b)
25a. from this case: $ _________
25b. from other case(s): _________
26. $______ TOTAL DEDUCTIONS ALLOWABLE UNDER SECTION 61.30, FLORIDA STATUTES
(Add lines 18 through 25).
27. $______ PRESENT NET MONTHLY INCOME
(Subtract line 26 from line 17).
SECTION II. AVERAGE MONTHLY EXPENSES
Proposed/Estimated Expenses. If this is a dissolution of marriage case and your expenses as listed
below do not reflect what you actually pay currently, you should write “estimate” next to each amount
that is estimated.
HOUSEHOLD:
1. $______ Monthly mortgage or rent payments
2. _______ Monthly property taxes (if not included in mortgage)
3. _______ Monthly insurance on residence (if not included in mortgage)
4. _______ Monthly condominium maintenance fees and homeowner’s association fees
5. _______ Monthly electricity
6. _______ Monthly water, garbage, and sewer
7. _______ Monthly telephone
8. _______ Monthly fuel oil or natural gas
9. _______ Monthly repairs and maintenance
10. _______ Monthly lawn care
11. _______ Monthly pool maintenance
12. _______ Monthly pest control
13. _______ Monthly misc. household
14. _______ Monthly food and home supplies
15. _______ Monthly meals outside home
16. _______ Monthly cable t.v.
17. _______ Monthly alarm service contract
18. _______ Monthly service contracts on appliances
19. _______ Monthly maid service
Other:
20. __________________________________________________________________________________
21. __________________________________________________________________________________
22. __________________________________________________________________________________
23. __________________________________________________________________________________
24. __________________________________________________________________________________
25. $_______ SUBTOTAL (add lines 1 through 24).
Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (Long Form) (01/15)
AUTOMOBILE:
26. $______ Monthly gasoline and oil
27. _______ Monthly repairs
28. _______ Monthly auto tags and emission testing
29. _______ Monthly insurance
30. _______ Monthly payments (lease or financing)
31. _______ Monthly rental/replacements
32. _______ Monthly alternative transportation (bus, rail, car pool, etc.)
33. _______ Monthly tolls and parking
34. _______ Other: _________________________________________________
35. $_______ SUBTOTAL (add lines 26 through 34)
MONTHLY EXPENSES FOR CHILDREN COMMON TO BOTH PARTIES:
36. $______ Monthly nursery, babysitting, or day care
37. _______ Monthly school tuition
38. _______ Monthly school supplies, books, and fees
39. _______ Monthly after school activities
40. _______ Monthly lunch money
41. _______ Monthly private lessons or tutoring
42. _______ Monthly allowances
43. _______ Monthly clothing and uniforms
44. _______ Monthly entertainment (movies, parties, etc.)
45. _______ Monthly health insurance
46. _______ Monthly medical, dental, prescriptions (nonreimbursed only)
47. _______ Monthly psychiatric/psychological/counselor
48. _______ Monthly orthodontic
49. _______ Monthly vitamins
50. _______ Monthly beauty parlor/barber shop
51. _______ Monthly nonprescription medication
52. _______ Monthly cosmetics, toiletries, and sundries
53. _______ Monthly gifts from child(ren) to others (other children, relatives, teachers, etc.)
54. _______ Monthly camp or summer activities
55. _______ Monthly clubs (Boy/Girl Scouts, etc.)
56. _______ Monthly time-sharing expenses
57. _______ Monthly miscellaneous
58. $_______ SUBTOTAL (add lines 36 through 57)
MONTHLY EXPENSES FOR CHILD(REN) FROM ANOTHER RELATIONSHIP
(other than court-ordered child support)
59. $________________________________________________________________________________
60. __________________________________________________________________________________
61. __________________________________________________________________________________
62. __________________________________________________________________________________
63. $_______ SUBTOTAL (add lines 59 through 62)
Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (Long Form) (01/15)
MONTHLY INSURANCE:
64. $______ Health insurance (if not listed on lines 23 or 45)
65. _______ Life insurance
66. _______ Dental insurance.
Other:
67.________________________________________________________________________________
68.________________________________________________________________________________
69.. $_______ SUBTOTAL (add lines 66 through 68, exclude lines 64 and 65)
OTHER MONTHLY EXPENSES NOT LISTED ABOVE:
70. $______ Monthly dry cleaning and laundry
71. _______ Monthly clothing
72. _______ Monthly medical, dental, and prescription (unreimbursed only)
73. _______ Monthly psychiatric, psychological, or counselor (unreimbursed only)
74. _______ Monthly non-prescription medications, cosmetics, toiletries, and sundries
75. _______ Monthly grooming
76._______ Monthly gifts
77._______ Monthly pet expenses
78._______ Monthly club dues and membership
79._______ Monthly sports and hobbies
80._______ Monthly entertainment
81._______ Monthly periodicals/books/tapes/CDs
82._______ Monthly vacations
83._______ Monthly religious organizations
84._______ Monthly bank charges/credit card fees
85._______ Monthly education expenses
86.______ Other: (include any usual and customary expenses not otherwise mentioned in the items
listed above)______________________________________________________________
87.__________________________________________________________________________________
88.__________________________________________________________________________________
89.__________________________________________________________________________________
90. $_______ SUBTOTAL (add lines 70 through 89)
MONTHLY PAYMENTS TO CREDITORS: (only when payments are currently made by you on outstanding
balances). List only last 4 digits of account numbers.
MONTHLY PAYMENT AND NAME OF CREDITOR(s):
91. $_________________________________________________________________________________
92.__________________________________________________________________________________
93.__________________________________________________________________________________
94.__________________________________________________________________________________
95.__________________________________________________________________________________
96.__________________________________________________________________________________
97.__________________________________________________________________________________
98.__________________________________________________________________________________
99.__________________________________________________________________________________
100.______________________________________________________________________________
101.______________________________________________________________________________
102.______________________________________________________________________________
Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (Long Form) (01/15)
103.______________________________________________________________________________
104. $_______ SUBTOTAL (add lines 91 through 103)
105. $_______TOTAL MONTHLY EXPENSES:
(add lines 25, 35, 58, 63, 69, 90, and 104 of Section II, Expenses)
SUMMARY
106. $_______ TOTAL PRESENT MONTHLY NET INCOME (from line 27 of SECTION I. INCOME)
107. $_______ TOTAL MONTHLY EXPENSES (from line 105 above)
108. $_______ SURPLUS (If line 106 is more than line 107, subtract line 107 from line 106. This is the
amount of your surplus. Enter that amount here.)
109. ($______)(DEFICIT) (If line 107 is more than line 106, subtract line 106 from line 107. This is
the amount of your deficit. Enter that amount here.)
SECTION III. ASSETS AND LIABILITIES
A. ASSETS (This is where you list what you OWN.)
INSTRUCTIONS:
STEP 1: In column A, list a description of each separate item owned by you (and/or your spouse, if
this is a petition for dissolution of marriage). Blank spaces are provided if you need to list more than
one of an item.
STEP 2: If this is a petition for dissolution of marriage, check the line in Column A next to any item
that you are requesting the judge award to you.
STEP 3: In column B, write what you believe to be the current fair market value of all items listed.
STEP 4: Use column C only if this is a petition for dissolution of marriage and you believe an item
is “nonmarital,” meaning it belongs to only one of you and should not be divided. You should
indicate to whom you believe the item belongs. (Typically, you will only use Column C if property
was owned by one spouse before the marriage. See the “General Information for Self-Represented
Litigants” found at the beginning of these forms and section 61.075(1), Florida Statutes, for
definitions of “marital” and “nonmarital” assets and liabilities.)
A
ASSETS: DESCRIPTION OF ITEM(S)
LIST ONLY LAST FOUR DIGITS OF ACCOUNT NUMBERS.
Check the line next to any asset(s) which you are requesting the judge award
to you.
B
Current
Fair
Market
Value
C
Nonmarital
(Check correct
column)
husband
wife
Cash (on hand)
$
Cash (in banks or credit unions)
Stocks/Bonds
Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (Long Form) (01/15)
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 Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (Long Form) (01/15)
B. LIABILITIES/DEBTS (This is where you list what you OWE.)
INSTRUCTIONS:
STEP 1: In column A, list a description of each separate debt owed by you (and/or your spouse, if
this is a petition for dissolution of marriage). Blank spaces are provided if you need to list more than
one of an item.
STEP 2: If this is a petition for dissolution of marriage, check the line in Column A next to any debt(s)
for which you believe you should be responsible.
STEP 3: In column B, write what you believe to be the current amount owed for all items listed.
STEP 4: Use column C only if this is a petition for dissolution of marriage and you believe an item
is “nonmarital,” meaning the debt belongs to only one of you and should not be divided. You
should indicate to whom you believe the debt belongs. (Typically, you will only use Column C if the
debt was owed by one spouse before the marriage. See the “General Information for Self-
Represented Litigants” found at the beginning of these forms and section 61.075(1), Florida
Statutes, for definitions of “marital” and “nonmarital” assets and liabilities.)
Jewelry
Life insurance (cash surrender value)
Sporting and entertainment (T.V., stereo, etc.) equipment
Other assets:
Total Assets (add column B)
$
Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (Long Form) (01/15)
A
LIABILITIES: DESCRIPTION OF ITEM(S)
LIST ONLY LAST FOUR DIGITS OF ACCOUNT NUMBERS.
Check the line next to any debt(s) for which you believe you should be
responsible.
B
Current
Amount
Owed
C
Nonmarital
(Check correct
column)
husband
wife
Mortgages on real estate: First mortgage on home
$
Second mortgage on home
Other mortgages
Charge/credit card accounts
Auto loan
Auto loan
Bank/Credit Union loans
Money you owe (not evidenced by a note)
Judgments
Other:
Total Debts (add column B)
$
Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (Long Form) (01/15)
C. NET WORTH (excluding contingent assets and liabilities)
$_______Total Assets (enter total of Column B in Asset Table; Section A)
$_______Total Liabilities (enter total of Column B in Liabilities Table; Section B)
$_______TOTAL NET WORTH (Total Assets minus Total Liabilities)
(excluding contingent assets and liabilities)
D. CONTINGENT ASSETS AND LIABILITIES
INSTRUCTIONS:
If you have any POSSIBLE assets (income potential, accrued vacation or sick leave, bonus,
inheritance, etc.) or POSSIBLE liabilities (possible lawsuits, future unpaid taxes, contingent tax
liabilities, debts assumed by another), you must list them here.
A
Contingent Assets
Check the line next to any contingent asset(s) which you are requesting the
judge award to you.
B
Possible
Value
C
Nonmarital
(Check correct
column)
husband
wife
$
Total Contingent Assets
$
A
Contingent Liabilities
Check the line next to any contingent debt(s) for which you believe you
should be responsible.
B
Possible
Amount
Owed
C
Nonmarital
(Check correct
column)
husband
wife
$
Total Contingent Liabilities
$
E. CHILD SUPPORT GUIDELINES WORKSHEET. Florida Family Law Rules of Procedure Form 12.902(e),
Child Support Guidelines Worksheet, MUST be filed with the court at or prior to a hearing to
Florida Family Law Rules of Procedure Form 12.902(c), Family Law Financial Affidavit (Long Form) (01/15)
establish or modify child support. This requirement cannot be waived by the parties.
[Check one only]
____A Child Support Guidelines Worksheet IS or WILL BE filed in this case. This case involves the
establishment or modification of child support.
____A Child Support Guidelines Worksheet IS NOT being filed in this case. The establishment or
modification of child support is not an issue in this case.
I certify that a copy of this financial affidavit was [check all used]: ( ) 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: _________________________
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: ______________________________
Fax 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: {choose only one} ( ) Petitioner ( ) Respondent
This form was completed with the assistance of:
{name of individual} ___________________________________________________________,
{name of business} _______________________________________________________________,
{address} ___________________________,
{city} ____,{state} _, {telephone number} ______________________.
Instructions to Florida Family Law Rules of Procedure Form 12.932, Certificate of Compliance with Mandatory
Disclosure (09/12)
INSTRUCTIONS FOR FLORIDA FAMILY LAW RULES OF PROCEDURE FORM
12.932, CERTIFICATE OF COMPLIANCE WITH MANDATORY DISCLOSURE
(09/12)
When should this form be used?
Mandatory disclosure
requires each party in a dissolution of marriage case to provide the other party
with certain financial information and documents. These documents must be served on the other party
within 45 days of service
of the petition for dissolution of marriage or supplemental petition for
modification on the respondent
. The mandatory disclosure rule applies to all original and supplemental
dissolution of marriage cases, except simplified dissolution of marriage cases and cases where the
respondent is served by constructive service
and does not answer. You should use this form to notify
the court and the other party that you have complied with the mandatory disclosure rule.
Each party must provide the other party with the documents listed in section 2 of this form if the
relief being sought is permanent regardless of whether it is an initial or supplemental proceeding.
ONLY THE ORIGINAL OF THE COMPLETED FORM IS FILED WITH THE COURT. EXCEPT FOR THE
FINANCIAL AFFIDAVIT AND CHILD SUPPORT GUIDELINES WORKSHEET, NO DOCUMENTS SHALL BE
FILED IN THE COURT FILE WITHOUT A PRIOR COURT ORDER. THE DOCUMENTS LISTED ON THE FORM
ARE TO BE GIVEN TO THE OTHER PARTY. If your individual gross annual income is under $50,000, you
should complete the Family Law Financial Affidavit (Short Form), Florida Family Law Rules of Procedure
Form 12.902(b). If your individual gross annual income is $50,000 or more, you should complete the
Family Law Financial Affidavit (Long Form), Florida Family Law Rules of Procedure Form 12.902(c).
In addition, there are separate mandatory disclosure requirements that apply to temporary financial
hearings, which are listed in section 1 of this form. The party seeking temporary financial relief must
serve these documents on the other party with the notice of temporary financial hearing. The
responding party must serve the required documents on the party seeking temporary relief. Service by
e-mail or mail shall be at least 7 days before the temporary financial relief hearing. Service by delivery
shall be no later than 5:00 p.m., 2 business days before the hearing. Any documents that have already
been served under the requirements for temporary or initial proceedings do not need to be reserved
again in the same proceeding. If a supplemental petition is filed, seeking modification, then the
mandatory disclosure requirements begin again.
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.
Instructions to Florida Family Law Rules of Procedure Form 12.932, Certificate of Compliance with Mandatory
Disclosure (09/12)
What should I do next?
After you have provided the other party all of the financial information and documents and have filed
this form certifying that you have complied with this rule, you are under a continuing duty to promptly
give the other party any information or documents that change your financial status or that make the
information already provided inaccurate. You should not file with the clerk any of the documents listed
in the certificate of compliance other than the financial affidavit and the child support guidelines
worksheet. Refer to the instructions regarding the petition
in your case to determine how you should
proceed after filing this 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 Florida Family Law Rule of Procedure 12.285.
Special notes…
You may provide copies of required documents; however, the originals must be produced for
inspection if the other party requests to see them.
Although the financial affidavits are based on individual gross income, either party may ask the other
party to complete the Family Law Financial Affidavit (Long Form), Florida Family Law Rules of
Procedure Form 12.902(c), by serving the appropriate interrogatory form. (See Standard Family Law
Interrogatories, Florida Family Law Rules of Procedure Form 12.930(b) (original proceedings) or (c)
(modification proceedings)).
Any portion of the mandatory disclosure rule may be modified by order of the
judge
or agreement of
the parties. Therefore, you and your spouse
may agree that you will not require each other to
produce the documents required under the mandatory disclosure rule. This exception does not apply
to the Financial Affidavit, Family Law Rules of Procedure Form 12.902(b) or (c), which is required in all
cases and cannot be waived.
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 Family Law Rules of Procedure Form 12.932, Certificate of Compliance with Mandatory Disclosure (09/12)
IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL CIRCUIT,
IN AND FOR PINELLAS COUNTY, FLORIDA
Case No.:
Division:
,
Petitioner,
and
,
Respondent.
CERTIFICATE OF COMPLIANCE WITH MANDATORY DISCLOSURE
ONLY THE ORIGINAL OF THIS COMPLETED FORM IS
FILED WITH THE COURT. EXCEPT FOR THE FINANCIAL
AFFIDAVIT AND CHILD SUPPORT GUIDELINES WORKSHEET,
NO DOCUMENTS SHALL BE FILED IN THE COURT FILE
WITHOUT A PRIOR COURT ORDER.
THE DOCUMENTS
LISTED BELOW ARE TO BE GIVEN TO THE OTHER PARTY.
I, {full legal name}
, certify that I have complied
with the mandatory disclosure required by Florida Family Law Rule 12.285 as follows:
1. FOR TEMPORARY FINANCIAL RELIEF, ONLY:
The date the following documents were served:
.
[Check all that apply]
a. ____ Financial Affidavit
( ) Florida Family Law Rules of Procedure Form 12.902(b) (short form)
( ) Florida Family Law Rules of Procedure Form 12.902(c) (long form)
b. ____ All personal (1040) federal tax, gift tax, and intangible personal property tax
returns for the preceding year; or
( ) Transcript of tax return as provided by IRS form 4506-T; or
( ) IRS forms W-2, 1099, and K-1 for the past year because the income tax return
for the past year has not been prepared.
c. ____ Pay stubs or other evidence of earned income for the 3 months before the service of the
financial affidavit.
2. FOR INITIAL, SUPPLEMENTAL, AND PERMANENT FINANCIAL RELIEF:
The date the following documents were served:
.
[Check all that apply]
a. ____ Financial Affidavit
( ) Florida Family Law Rules of Procedure Form 12.902(b) (short form)
Florida Family Law Rules of Procedure Form 12.932, Certificate of Compliance with Mandatory Disclosure (09/12)
( ) Florida Family Law Rules of Procedure Form 12.902(c) (long form)
b. ____ All personal (1040) federal and state income tax returns, gift tax returns, and
intangible personal property tax returns for the preceding 3 years;
( ) IRS forms W-2, 1099, and K-1 for the past year because the income tax return
for the past year has not been prepared.
c. ____ Pay stubs or other evidence of earned income for the 3 months before the service of the
financial affidavit.
d. ___ A statement identifying the source and amount of all income for the 3 months before
the service of the financial affidavit, if not reflected on the pay stubs produced.
e. ___ All loan applications and financial statements prepared for any purpose or used for any
purpose within the 12 months preceding the service of the financial affidavit.
f. ___ All deeds to real estate in which I presently own or owned an interest within the
past 3 years. All promissory notes in which I presently own or owned an interest
within the last 12 months. All present leases in which I own an interest.
g. ___ All periodic statements for the last 3 months for all checking accounts and for the last
year for all savings accounts, money market funds, certificates of deposit, etc.
h. ___ All brokerage account statements for the last 12 months.
i. ___ Most recent statement for any pension, profit sharing, deferred compensation, or
retirement plan (for example, IRA, 401(k), 403(b), SEP, KEOGH, etc.) and summary plan
description for any such plan in which I am a participant or alternate payee.
j. ___ The declaration page, the last periodic statement, and the certificate for any group
insurance for all life insurance policies insuring my life or the life of me or my spouse.
k. ___ All health and dental insurance cards covering either me or my spouse and/or our
dependent child(ren).
l. ___ Corporate, partnership, and trust tax returns for the last 3 tax years, in which I have an
ownership or interest greater than or equal to 30%.
m. ___ All credit card and charge account statements and other records showing my (our)
indebtedness as of the date of the filing of this action and for the prior 3 months. All
promissory notes on which I presently owe or owned within the past year. All lease
agreements I presently owe.
n. ___ All premarital and marital agreements between the parties to this case.
o. ___ If a modification proceeding, all written agreements entered into between the parties
at any time since the order to be modified was entered.
p. ___ All documents and tangible evidence relating to claims for an unequal distribution of
marital property, enhancement or appreciation in nonmarital property, or nonmarital
status of an asset or debt.
q. ___ Any court order directing that I pay or receive spousal support (alimony) or child
support.
I certify that a copy of this document was [check all used]: ( ) 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: ___________________________________
E-mail Address(es):_______________________________
Florida Family Law Rules of Procedure Form 12.932, Certificate of Compliance with Mandatory Disclosure (09/12)
I understand that I am swearing or affirming under oath to the accuracy of my compliance with the
mandatory disclosure requirements of Florida Family Law Rule of Procedure 12.285 and that, unless
otherwise indicated with specificity, this disclosure is complete. I further understand that the
punishment for knowingly making a false statement or incomplete disclosure includes fines and/or
imprisonment.
Dated: ____________________
____________________________________
Signature of Party
Printed Name: _________________________
Address: _____________________________
City, State, Zip:_________________________
Telephone Number: ____________________
Fax 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
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}______, {telephone number}________________.
WAIVER OF MANDATORY DISCLOSURE*
INSTRUCTIONS FOR USE
Rule 12.285, Florida Family Court Rules of Procedure, requires that each party to any
Dissolution of Marriage action which may involve some financial/asset issues (except those
cases specifically filed as a Simplified Dissolution of Marriage) provide certain documentation to
the other party so that each will be fully informed about the financial circumstances of the
opposition for settlement discussions and so that sufficient evidence may be presented to the
Court for a proper decision on the financial issues if the case is not settled before trial. The Rule
specifically lists the documents to be provided (known in general as “discovery”), at what stage
of the proceeding disclosure must be made, and the extent of the disclosure necessary based upon
the income and expenses of each party.
In many cases, however, it is not necessary to provide all of the documents listed in the
Rule. This is usually when the parties have agreed by written Marital Settlement Agreement to a
resolution of all of the potentially contested issues and are satisfied that the Agreement is fair to
each and that each fully understood the financial circumstances of the opposing party at the time
of making the Agreement. In those cases, the parties can agree to waive most
of the disclosure
requirements of Rule 12.285 (the requirement that each party file a completed Financial
Affidavit cannot be waived and the Affidavit must be filed).
If both you and your spouse fit into the above category of litigants you may file a Waiver
of Mandatory Disclosure with the Court. If you agree to waive everything (except the Financial
Affidavit), check every line on the form. If you agree to waive only part of the "mandatory"
disclosure, check only those items that each of you agree do not need to be reviewed before you
appear in Court. The form needs to be signed by both you and your spouse.
Signing and filing the Waiver of Mandatory Disclosure form, however, does not
guarantee that the documents will not be needed. The Judge or General Master who hears your
case may want additional information before he/she can find that the Marital Settlement
Agreement is, in fact, legally fair and equitable to both you and your spouse or is otherwise
acceptable to the Court. Although this will not be known until the hearing, filing the Waiver of
Mandatory Disclosure, if you are satisfied with your level of understanding, will be beneficial to
the Court and will possibly avoid unnecessary delay in the proceedings.
*Use either Certificate of Compliance with Mandatory Disclosure or Waiver of Mandatory
Disclosure form.
Instructions for Sixth Judicial Circuit Local Form-Waiver of Mandatory Disclosure - Reviewed 2/2006
PINELLAS
Instructions for Florida Family Law Rules of Procedure Form 12.910(a), Summons: Personal Service on an
Individual (03/17)
INSTRUCTIONS FOR FLORIDA FAMILY LAW RULES OF PROCEDURE FORM
12.910(a)
SUMMONS: PERSONAL SERVICE ON AN INDIVIDUAL
(03/17)
When should this form be used?
This form should be used to obtain personal service on the other party when you begin your lawsuit.
Service is required for all documents filed in your case. Service means giving a copy of the required papers
to the other party using the procedure that the law requires. Generally, there are two ways to make
service: (1) personal service, or (2) service by email, mail, or hand delivery. A third method for service is
called constructive service; however, the relief a court may grant may be limited in a case where
constructive service has been used.
The law requires that certain documents be served by personal service if personal service is possible.
Personal service means that a summons (this form) and a copy of the forms you are filing with the court
that must be personally served are delivered by a deputy sheriff or private process server
a. directly to the other party, or
b. to someone over the age of fifteen with whom the other party lives.
Personal service is required for all petitions, including petitions for modification. You cannot serve these
papers on the other party yourself or by mail or hand delivery. Personal service must be made by the
sheriff’s department in the county where the other party lives or works or by a private process server
certified in the county where the other party lives or works.
In many counties, there are private process servers who, for a fee, will personally serve the summons and
other documents that require personal service. You should look under process servers in the yellow pages
of the telephone book for a list of private process servers in your area. You may use a private process
server to serve any paper required to be personally served in a family law case except a petition for
injunction for protection against domestic or repeat violence.
How do I start?
When you begin your lawsuit, you need to complete this form (summons) and a Process Service
Memorandum, Florida Supreme Court Approved Family Law Form 12.910(b). The forms should be typed
or printed legibly in black ink. Next, you will need to take these forms and, if you have not already done
so, file your petition with the clerk of the circuit court in the county where you live. You should keep a
copy of the forms for your records. The clerk will sign the summons, and then the summons, a copy of the
papers to be served, and the process service memorandum must be delivered to the appropriate sheriff’s
office or to a private process server for service on the other party.
IF THE OTHER PARTY LIVES IN THE COUNTY WHERE SUIT IS FILED: Ask the clerk in your county about any
local procedures regarding service. Generally, if the other party lives in the county in which you are filing
suit and you want the sheriff’s department to serve the papers, you will file the summons along with a
Instructions for Florida Family Law Rules of Procedure Form 12.910(a), Summons: Personal Service on an
Individual (03/17)
Process Service Memorandum, Florida Supreme Court Approved Family Law Form 12.910(b), with the
clerk and the clerk will forward those papers to the sheriff for service. Make sure that you attach a copy
of the papers you want personally served to the summons. You may also need to provide the sheriff with
a stamped envelope addressed to you. This will allow the sheriff to send the proof of service to you, after
the sheriff serves your papers on the other party. However, in some counties the sheriff may send the
proof of service directly to the clerk. If you are instructed to supply a self-addressed, stamped envelope
and you receive the proof of service, you should file the proof of service with the clerk after you receive
it from the sheriff. Also, you will need to find out how much the sheriff charges to serve the papers.
Personal checks are not accepted. You should attach to the summons a cashier’s check or money order
made payable to the sheriff, and either give it to the clerk for delivery to the sheriff or send all of the
paperwork and the fee to the sheriff yourself. The clerk will tell you which procedure to use. The costs for
service may be waived if you are indigent.
If you want a private process server to serve the other party, you should still bring the summons to the
clerk’s office and have the clerk sign it for you. You should deliver the summons, along with the copy of
your initial petition and any other papers to be served, and a Process Service Memorandum, Florida
Supreme Court Approved Family Law Form 12.910(b), to the private process server. The private process
server will charge you a fee for serving the papers. After service is complete, proof of service by the
private process server must be filed with the clerk. You should discuss how this will occur with the private
process server.
IF THE OTHER PARTY LIVES IN ANOTHER COUNTY: If the other party lives in another county, service needs
to be made by a sheriff in the county where the other party lives or by a private process server certified
in the county where the other party lives. Make sure that you attach a copy of the papers you want
personally served to the summons as well as the Process Service Memorandum, Florida Supreme Court
Approved Family Law Form 12.910(b). If you want the sheriff to serve the papers, the clerk may send your
papers to that sheriff’s office for you, or you may have to send the papers yourself. The clerk will tell you
which procedure to use. Either way, you will need to provide the sheriff with a stamped envelope
addressed to you. This will allow the sheriff to send the proof of service to you, after the sheriff serves
your papers on the other party. You should file the proof of service with the clerk after you receive it from
the sheriff. Also, you will need to find out how much the sheriff charges to serve the papers. Personal
checks are not accepted. You should attach to the summons a cashier’s check or money order made
payable to the sheriff, and either give it to the clerk for delivery to the sheriff or send all of the paperwork
and the fee to the sheriff yourself. The clerk will tell you which procedure to use. The costs for service
may be waived if you are indigent.
If you want a private process server to serve the other party, you should still bring the summons to the
clerk’s office where the clerk will sign it for you. You should deliver the summons, along with the copy of
your initial petition and any other papers to be served, and a Process Service Memorandum, Florida
Supreme Court Approved Family Law Form 12.910(b), to the private process server. The private process
server will charge you a fee for serving the papers. After service is complete, proof of service by the
private process server must be filed with the clerk. You should discuss how this will occur with the private
process server.
IF THE OTHER PARTY CANNOT BE LOCATED OR DOES NOT LIVE IN FLORIDA: If, after you have made a
diligent effort to locate the other party, you absolutely cannot locate the other party, you may serve the
other party by publication. Service by publication is also known as constructive service. You may also be
able to use constructive service if the other party does not live in Florida. However, Florida courts have
only limited jurisdiction over a party who is served by constructive service and may have only limited
Instructions for Florida Family Law Rules of Procedure Form 12.910(a), Summons: Personal Service on an
Individual (03/17)
jurisdiction over a party living outside of Florida regardless of whether that party is served by
constructive or personal service; that is, the judge’s power to order the other party to do certain things
may be limited. For example, the judge may be able to grant your request for a divorce, but the judge
may not be able to address issues such as child support, spousal support (alimony), or division of property
or debts.
Regardless of the type of service used, if the other party once lived in Florida but is living outside of Florida
now, you should include in your petition a statement regarding the length of time the party lived in Florida,
if any, and when. For example: “Respondent last lived in Florida from {date} to
{date} .”
This area of the law is very complex and you may need to consult with an attorney regarding the proper
type of service to be used in your case if the other party does not live in Florida or cannot be located.
What happens when the papers are served on the other party?
The date and hour of service are written on the original summons and on all copies of it by the person
making the service. The person who delivers the summons and copies of the petition must file a proof of
service with the clerk or provide a proof of service to you for filing with the court. It is your responsibility
to make sure the proof of service has been returned to the clerk and placed in your case file.
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 regarding service of process, see chapters 48 and 49,
Florida Statutes, and Florida Family Law Rule of Procedure 12.070, as well as the instructions for Notice
of Action for Dissolution of Marriage (No Child or Financial Support), Florida Supreme Court Approved
Family Law Form 12.913(a)(1), Notice of Action for Family Cases with Minor Child(ren), Florida Supreme
Court Approved Family Law Form 12.913(a)(2), Affidavit of Diligent Service and Inquiry, Florida Family
Law Rules of Procedure Form 12.913(b), and Affidavit of Diligent Search, Florida Family Law Rules of
Procedure Form 12.913(c).
Special notes
If you have been unable to obtain proper service on the other party within 120 days after filing your
lawsuit, the court will dismiss your lawsuit against the other party unless you can show the court a good
reason why service was not made within 120 days. For this reason, if you had the local sheriff serve the
papers, you should check with the clerk every couple of weeks after completing the service papers to see
if service has been completed. You may need to supply the sheriff with a new or better address. If you
had a private process server or a sheriff in another county serve the papers, you should be in contact with
that person or sheriff until you receive proof of service from that person or sheriff. You should then file
the proof of service with the clerk immediately.
If the other party fails to respond, i.e., fails to file a written response with the court, within 20 days after
the service of the summons, you are entitled to request a default. See the instructions to 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), for further information. You will need to file an Affidavit of Military
Service, Florida Supreme Court Approved Family Law Form 12.912(b), before a default may be granted.
Instructions for Florida Family Law Rules of Procedure Form 12.910(a), Summons: Personal Service on an
Individual (03/17)
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.
Florida Family Law Rules of Procedure Form 12.910(a), Summons: Personal Service on an Individual (03/17)
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA
Case No.:
Division:
,
Petitioner,
and
,
Respondent.
SUMMONS: PERSONAL SERVICE ON AN INDIVIDUAL
ORDEN DE COMPARECENCIA: SERVICIO PERSONAL EN UN INDIVIDUO
CITATION: L’ASSIGNATION PERSONAL SUR UN INDIVIDUEL
TO/PARA/A: {enter other party’s full legal name} ,
{address (including city and state)/location for service} .
IMPORTANT
A lawsuit has been filed against you. You have 20 calendar days after this summons is served on you to
file a written response to the attached complaint/petition with the clerk of this circuit court, located at:
{street address} _______________________________________________________________________.
A phone call will not protect you. Your written response, including the case number given above and the
names of the parties, must be filed if you want the Court to hear your side of the case.
If you do not file your written response on time, you may lose the case, and your wages, money, and
property may be taken thereafter without further warning from the Court. There are other legal
requirements. You may want to call an attorney right away. If you do not know an attorney, you may call
an attorney referral service or a legal aid office (listed in the phone book).
If you choose to file a written response yourself, at the same time you file your written response to the
Court, you must also serve a copy of your written response on the party serving this summons at:
{Name and address of party serving summons}
.
If the party serving summons has designated email address(es) for service or is represented by an
attorney, you may designate email address(es) for service by or on you. Service must be in accordance
with Florida Rule of Judicial Administration 2.516.
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 Email Address, Florida Supreme Court Approved Family Law Form
Florida Family Law Rules of Procedure Form 12.910(a), Summons: Personal Service on an Individual (03/17)
12.915.) Future papers in this lawsuit will be mailed to the address 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.
IMPORTANTE
Usted ha sido demandado legalmente. Tiene veinte (20) dias, contados a partir del recibo de esta
notificacion, para contestar la demanda adjunta, por escrito, y presentarla ante este tribunal. Localizado
en: . Una llamada telefonica no lo protegera. Si usted desea
que el tribunal considere su defensa, debe presentar su respuesta por escrito, incluyendo el numero del
caso y los nombres de las partes interesadas. Si usted no contesta la demanda a tiempo, pudiese perder
el caso y podria ser despojado de sus ingresos y propiedades, o privado de sus derechos, sin previo aviso
del tribunal. Existen otros requisitos legales. Si lo desea, usted puede consultar a un abogado
inmediatamente. Si no conoce a un abogado, puede llamar a una de las oficinas de asistencia legal que
aparecen en la guia telefonica.
Si desea responder a la demanda por su cuenta, al mismo tiempo en que presente su respuesta ante el
tribunal, usted debe enviar por correo o entregar una copia de su respuesta a la persona denominada
abajo.
Si usted elige presentar personalmente una respuesta por escrito, en el mismo momento que usted
presente su respuesta por escrito al Tribunal, usted debe enviar por correo o llevar una copia de su
respuesta por escrito a la parte entregando esta orden de comparencencia a:
Nombre y direccion de la parte que entrega la orden de comparencencia:
.
Copias de todos los documentos judiciales de este caso, incluyendo las ordenes, estan disponibles en la
oficina del Secretario de Juzgado del Circuito [Clerk of the Circuit Court’s office]. Estos documentos
pueden ser revisados a su solicitud.
Usted debe de manener informada a la oficina del Secretario de Juzgado del Circuito de su direccion
actual. (Usted puede presentar el Formulario: Ley de Familia de la Florida 12.915, Florida Supreme
Court Approved Family Law Form 12.915, [Designation of Current Mailing and Email Address].) Los
papelos que se presenten en el futuro en esta demanda judicial seran env ados por correo a la direccion
que este registrada en la oficina del Secretario.
ADVERTENCIA: Regla 12.285 (Rule 12.285), de las Reglas de Procedimiento de Ley de Familia de la
Florida [Florida Family Law Rules of Procedure], requiere cierta revelacion automatica de documentos
e informacion. El incumplimient, puede resultar en sanciones, incluyendo la desestimacion o anulacion
de los alegatos.
IMPORTANT
Des poursuites judiciaries ont ete entreprises contre vous. Vous avez 20 jours consecutifs a partir de la
date de l’assignation de cette citation pour deposer une reponse ecrite a la plainte ci-jointe aupres de ce
tribunal. Qui se trouve a: {L’Adresse} . Un simple coup de telephone est
insuffisant pour vous proteger; vous etes obliges de deposer votre reponse ecrite, avec mention du
numero de dossier ci-dessus et du nom des parties nommees ici, si vous souhaitez que le tribunal entende
Florida Family Law Rules of Procedure Form 12.910(a), Summons: Personal Service on an Individual (03/17)
votre cause. Si vous ne deposez pas votre reponse ecrite dans le delai requis, vous risquez de perdre la
cause ainsi que votre salaire, votre argent, et vos biens peuvent etre saisis par la suite, sans aucun preavis
ulterieur du tribunal. Il y a d’autres obligations juridiques et vous pouvez requerir les services immediats
d’un avocat. Si vous ne connaissez pas d’avocat, vous pourriez telephoner a un service de reference
d’avocats ou a un bureau d’assistance juridique (figurant a l’annuaire de telephones).
Si vous choisissez de deposer vous-meme une reponse ecrite, il vous faudra egalement, en meme temps
que cette formalite, faire parvenir ou expedier une copie au carbone ou une photocopie de votre reponse
ecrite a la partie qui vous depose cette citation.
Nom et adresse de la partie qui depose cette citation:
Les photocopies de tous les documents tribunals de cette cause, y compris des arrets, sont disponible
au bureau du greffier. Vous pouvez revue ces documents, sur demande.
Il faut aviser le greffier de votre adresse actuelle. (Vous pouvez deposer Florida Supreme Court
Approved Family Law Form 12.915, Designation of Current Mailing and Email Address.) Les documents
de l’avenir de ce proces seront envoyer a l’adresse que vous donnez au bureau du greffier.
ATTENTION: La regle 12.285, des regles de procedure du droit de la famille de la Floride exige que l’on
remette certains renseignements et certains documents a la partie adverse. Tout refus de les fournir
pourra donner lieu a des sanctions, y compris le rejet ou la suppression d’un ou de plusieurs actes de
procedure.
THE STATE OF FLORIDA
TO EACH SHERIFF OF THE STATE: You are commanded to serve this summons and a copy of the complaint
in this lawsuit on the above-named person.
DATED:
CLERK OF THE CIRCUIT COURT
(SEAL)
By:
Deputy Clerk
Instructions for Florida Supreme Court Approved Family Law Form 12.910(b), Process Service Memorandum
(11/15)
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.910(b),
PROCESS SERVICE MEMORANDUM (11/15)
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
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.
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
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
Instructions for Florida Supreme Court Approved Family Law Form 12.910(b), Process Service Memorandum
(11/15)
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.
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.
Florida Supreme Court Approved Family Law Form 12.910(b), Process Service Memorandum (11/15)
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 (11/15)
* 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 Petitioner. This form was completed with the assistance
of:
{name of individual} ____________________________________________________________________,
{name of business} _____________________________________________________________________,
{address} ____________________________________________________________________________,
{city}_______________, {state} ____, {zip code} __________, {telephone number} ___________________
Instructions for Florida Supreme Court Approved Family Law Form 12.912(b), Affidavit of Military Service (11/15)
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.912(b), AFFIDAVIT OF MILITARY SERVICE (11/15)
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
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 12.912(b), Affidavit of Military Service (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.
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.
Florida Supreme Court Approved Family Law Form 12.912(b), Affidavit of Military Service (11/15)
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:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
I have no reason to believe that s/he is on active duty at this time.
Florida Supreme Court Approved Family Law Form 12.912(b), Affidavit of Military Service (11/15)
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} ____________________________________________________________________________,
{city}_________________,{state} _____, {zip code}_________,{telephone number}_________________.
Instructions for Florida Supreme Court Approved Family Law Forms 12.922(a), Motion for Default, and 12.922(b),
Default (11/15)
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY
LAW FORMS 12.922(a), MOTION FOR DEFAULT, AND 12.922(b),
DEFAULT (11/15)
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
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?
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.
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
Instructions for Florida Supreme Court Approved Family Law Forms 12.922(a), Motion for Default, and 12.922(b),
Default (11/15)
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.
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 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.
Florida Supreme Court Approved Family Law Form 12.922(a), Motion for Default (11/15)
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 Party
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 (11/15)
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 (11/15)
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 Party
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 (11/15)
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} ________________.
Instructions for Florida Family Law Rules of Procedure Form 12.902(e), Child Support Guidelines Worksheet
(09/12)
INSTRUCTIONS FOR FLORIDA FAMILY LAW RULES OF PROCEDURE FORM
12.902(e), CHILD SUPPORT GUIDELINES WORKSHEET (09/12)
When should this form be used?
You should complete this worksheet if child support
is being requested in your case. If you know the
income of the other party
, this worksheet should accompany your financial affidavit. If you do not
know the other party’s income, this form must be completed after the other party files his or her
financial affidavit, and serves
a copy on you.
This form should be typed or printed in black ink. 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.
What should I do next?
A copy of this form must be served on the other party in your case. Service must be in accordance with
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 section 61.30, Florida Statutes.
Special notes...
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 Request for
Confidential Filing of Address, Florida Supreme Court Approved Family Law Form 12.980(h).
The chart below contains the guideline amounts that you should use when calculating child support.
This amount is based on the number of children and the combined income of the parents, and it is
divided between the parents in direct proportion to their income or earning capacity. From time to
time, some of the amounts in the child support guidelines chart will change. Be sure you have the most
recent version of the chart before using it.
Because the guidelines are based on monthly amounts, it may be necessary to convert some income and
expense figures from other frequencies to monthly. You should do this as follows:
Instructions for Florida Family Law Rules of Procedure Form 12.902(e), Child Support Guidelines Worksheet
(09/12)
If payment is twice per month Payment amount x 2 = Monthly amount
If payment is every two weeks Payment amount x 26 = Yearly amount due
Yearly amount ÷ 12 = Monthly amount
If payment is weekly Weekly amount x 52 = Yearly amount due
Yearly amount ÷ 12 = Monthly amount
If you or the other parent request that the court award an amount that is different than the guideline
amount, you must also complete and attach a Motion to Deviate from Child Support Guidelines, Florida
Supreme Court Approved Family Law Form 12.943.
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 Family Law Rules of Procedure Form 12.902(e), Child Support Guidelines
Worksheet (09/12)
CHILD SUPPORT GUIDELINES CHART
Combined
Monthly
Available
Income
One
Child
Two
Children
Three
Children
Four
Children
Five
Children
Six
Children
800.00 190 211 213 216 218 220
850.00 202 257 259 262 265 268
900.00 213 302 305 309 312 315
950.00 224 347 351 355 359 363
1000.00 235 365 397 402 406 410
1050.00 246 382 443 448 453 458
1100.00 258 400 489 495 500 505
1150.00 269 417 522 541 547 553
1200.00 280 435 544 588 594 600
1250.00 290 451 565 634 641 648
1300.00 300 467 584 659 688 695
1350.00 310 482 603 681 735 743
1400.00 320 498 623 702 765 790
1450.00 330 513 642 724 789 838
1500.00 340 529 662 746 813 869
1550.00 350 544 681 768 836 895
1600.00 360 560 701 790 860 920
1650.00 370 575 720 812 884 945
1700.00 380 591 740 833 907 971
1750.00 390 606 759 855 931 996
1800.00 400 622 779 877 955 1022
1850.00 410 638 798 900 979 1048
1900.00 421 654 818 923 1004 1074
1950.00 431 670 839 946 1029 1101
2000.00 442 686 859 968 1054 1128
2050.00 452 702 879 991 1079 1154
2100.00 463 718 899 1014 1104 1181
2150.00 473 734 919 1037 1129 1207
2200.00 484 751 940 1060 1154 1234
2250.00 494 767 960 1082 1179 1261
2300.00 505 783 980 1105 1204 1287
2350.00 515 799 1000 1128 1229 1314
2400.00 526 815 1020 1151 1254 1340
2450.00 536 831 1041 1174 1279 1367
2500.00 547 847 1061 1196 1304 1394
2550.00 557 864 1081 1219 1329 1420
2600.00
2650.00
568
578
880
896
1101
1121
1242
1265
1354
1379
1447
1473
Instructions for Florida Family Law Rules of Procedure Form 12.902(e), Child Support Guidelines
Worksheet (09/12)
Combined
Monthly
Available
Income
One
Child
Two
Children
Three
Children
Four
Children
Five
Children
Six
Children
2700.00
2750.00
2800.00
2850.00
588
597
607
616
912
927
941
956
1141
1160
1178
1197
1287
1308
1328
1349
1403
1426
1448
1471
1500
1524
1549
1573
2900.00 626 971 1215 1370 1494 1598
2950.00 635 986 1234 1391 1517 1622
3000.00 644 1001 1252 1412 1540 1647
3050.00 654 1016 1271 1433 1563 1671
3100.00 663 1031 1289 1453 1586 1695
3150.00 673 1045 1308 1474 1608 1720
3200.00 682 1060 1327 1495 1631 1744
3250.00 691 1075 1345 1516 1654 1769
3300.00 701 1090 1364 1537 1677 1793
3350.00 710 1105 1382 1558 1700 1818
3400.00 720 1120 1401 1579 1723 1842
3450.00 729 1135 1419 1599 1745 1867
3500.00 738 1149 1438 1620 1768 1891
3550.00 748 1164 1456 1641 1791 1915
3600.00 757 1179 1475 1662 1814 1940
3650.00 767 1194 1493 1683 1837 1964
3700.00 776 1208 1503 1702 1857 1987
3750.00 784 1221 1520 1721 1878 2009
3800.00 793 1234 1536 1740 1899 2031
3850.00 802 1248 1553 1759 1920 2053
3900.00 811 1261 1570 1778 1940 2075
3950.00 819 1275 1587 1797 1961 2097
4000.00 828 1288 1603 1816 1982 2119
4050.00 837 1302 1620 1835 2002 2141
4100.00 846 1315 1637 1854 2023 2163
4150.00 854 1329 1654 1873 2044 2185
4200.00 863 1342 1670 1892 2064 2207
4250.00 872 1355 1687 1911 2085 2229
4300.00 881 1369 1704 1930 2106 2251
4350.00 889 1382 1721 1949 2127 2273
4400.00 898 1396 1737 1968 2147 2295
4450.00 907 1409 1754 1987 2168 2317
4500.00 916 1423 1771 2006 2189 2339
4550.00 924 1436 1788 2024 2209 2361
4600.00 933 1450 1804 2043 2230 2384
4650.00 942 1463 1821 2062 2251 2406
Instructions for Florida Family Law Rules of Procedure Form 12.902(e), Child Support Guidelines
Worksheet (09/12)
Combined
Monthly
Available
Income
One
Child
Two
Children
Three
Children
Four
Children
Five
Children
Six
Children
4700.00 951 1477 1838 2081 2271 2428
4750.00 959 1490 1855 2100 2292 2450
4800.00 968 1503 1871 2119 2313 2472
4850.00 977 1517 1888 2138 2334 2494
4900.00 986 1530 1905 2157 2354 2516
4950.00 993 1542 1927 2174 2372 2535
5000.00 1000 1551 1939 2188 2387 2551
5050.00 1006 1561 1952 2202 2402 2567
5100.00 1013 1571 1964 2215 2417 2583
5150.00 1019 1580 1976 2229 2432 2599
5200.00 1025 1590 1988 2243 2447 2615
5250.00 1032 1599 2000 2256 2462 2631
5300.00 1038 1609 2012 2270 2477 2647
5350.00 1045 1619 2024 2283 2492 2663
5400.00 1051 1628 2037 2297 2507 2679
5450.00 1057 1638 2049 2311 2522 2695
5500.00 1064 1647 2061 2324 2537 2711
5550.00 1070 1657 2073 2338 2552 2727
5600.00 1077 1667 2085 2352 2567 2743
5650.00 1083 1676 2097 2365 2582 2759
5700.00 1089 1686 2109 2379 2597 2775
5750.00 1096 1695 2122 2393 2612 2791
5800.00 1102 1705 2134 2406 2627 2807
5850.00 1107 1713 2144 2418 2639 2820
5900.00 1111 1721 2155 2429 2651 2833
5950.00 1116 1729 2165 2440 2663 2847
6000.00 1121 1737 2175 2451 2676 2860
6050.00 1126 1746 2185 2462 2688 2874
6100.00 1131 1754 2196 2473 2700 2887
6150.00 1136 1762 2206 2484 2712 2900
6200.00 1141 1770 2216 2495 2724 2914
6250.00 1145 1778 2227 2506 2737 2927
6300.00 1150 1786 2237 2517 2749 2941
6350.00 1155 1795 2247 2529 2761 2954
6400.00 1160 1803 2258 2540 2773 2967
6450.00 1165 1811 2268 2551 2785 2981
6500.00 1170 1819 2278 2562 2798 2994
6550.00 1175 1827 2288 2573 2810 3008
6600.00 1179 1835 2299 2584 2822 3021
6650.00 1184 1843 2309 2595 2834 3034
Instructions for Florida Family Law Rules of Procedure Form 12.902(e), Child Support Guidelines
Worksheet (09/12)
Combined
Monthly
Available
Income
One
Child
Two
Children
Three
Children
Four
Children
Five
Children
Six
Children
6700.00 1189 1850 2317 2604 2845 3045
6750.00 1193 1856 2325 2613 2854 3055
6800.00 1196 1862 2332 2621 2863 3064
6850.00 1200 1868 2340 2630 2872 3074
6900.00 1204 1873 2347 2639 2882 3084
6950.00 1208 1879 2355 2647 2891 3094
7000.00 1212 1885 2362 2656 2900 3103
7050.00 1216 1891 2370 2664 2909 3113
7100.00 1220 1897 2378 2673 2919 3123
7150.00 1224 1903 2385 2681 2928 3133
7200.00 1228 1909 2393 2690 2937 3142
7250.00 1232 1915 2400 2698 2946 3152
7300.00 1235 1921 2408 2707 2956 3162
7350.00 1239 1927 2415 2716 2965 3172
7400.00 1243 1933 2423 2724 2974 3181
7450.00 1247 1939 2430 2733 2983 3191
7500.00 1251 1945 2438 2741 2993 3201
7550.00 1255 1951 2446 2750 3002 3211
7600.00 1259 1957 2453 2758 3011 3220
7650.00 1263 1963 2461 2767 3020 3230
7700.00 1267 1969 2468 2775 3030 3240
7750.00 1271 1975 2476 2784 3039 3250
7800.00 1274 1981 2483 2792 3048 3259
7850.00 1278 1987 2491 2801 3057 3269
7900.00 1282 1992 2498 2810 3067 3279
7950.00 1286 1998 2506 2818 3076 3289
8000.00 1290 2004 2513 2827 3085 3298
8050.00 1294 2010 2521 2835 3094 3308
8100.00 1298 2016 2529 2844 3104 3318
8150.00 1302 2022 2536 2852 3113 3328
8200.00 1306 2028 2544 2861 3122 3337
8250.00 1310 2034 2551 2869 3131 3347
8300.00 1313 2040 2559 2878 3141 3357
8350.00 1317 2046 2566 2887 3150 3367
8400.00 1321 2052 2574 2895 3159 3376
8450.00 1325 2058 2581 2904 3168 3386
8500.00 1329 2064 2589 2912 3178 3396
8550.00 1333 2070 2597 2921 3187 3406
8600.00 1337 2076 2604 2929 3196 3415
8650.00 1341 2082 2612 2938 3205 3425
Instructions for Florida Family Law Rules of Procedure Form 12.902(e), Child Support Guidelines
Worksheet (09/12)
Combined
Monthly
Available
Income
One
Child
Two
Children
Three
Children
Four
Children
Five
Children
Six
Children
8700.00 1345 2088 2619 2946 3215 3435
8750.00 1349 2094 2627 2955 3224 3445
8800.00 1352 2100 2634 2963 3233 3454
8850.00 1356 2106 2642 2972 3242 3464
8900.00 1360 2111 2649 2981 3252 3474
8950.00 1364 2117 2657 2989 3261 3484
9000.00 1368 2123 2664 2998 3270 3493
9050.00 1372 2129 2672 3006 3279 3503
9100.00 1376 2135 2680 3015 3289 3513
9150.00 1380 2141 2687 3023 3298 3523
9200.00 1384 2147 2695 3032 3307 3532
9250.00 1388 2153 2702 3040 3316 3542
9300.00 1391 2159 2710 3049 3326 3552
9350.00 1395 2165 2717 3058 3335 3562
9400.00 1399 2171 2725 3066 3344 3571
9450.00 1403 2177 2732 3075 3353 3581
9500.00 1407 2183 2740 3083 3363 3591
9550.00 1411 2189 2748 3092 3372 3601
9600.00 1415 2195 2755 3100 3381 3610
9650.00 1419 2201 2763 3109 3390 3620
9700.00 1422 2206 2767 3115 3396 3628
9750.00 1425 2210 2772 3121 3402 3634
9800.00 1427 2213 2776 3126 3408 3641
9850.00 1430 2217 2781 3132 3414 3647
9900.00 1432 2221 2786 3137 3420 3653
9950.00 1435 2225 2791 3143 3426 3659
10000.00 1437 2228 2795 3148 3432 3666
Florida Family Law Rules of Procedure Form 12.902(e), Child Support Guidelines Worksheet (09/12)
IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL CIRCUIT,
IN AND FOR PINELLAS COUNTY, FLORIDA
Case No.:
Division:
,
Petitioner,
and
,
Respondent.
NOTICE OF FILING CHILD SUPPORT GUIDELINES WORKSHEET
PLEASE TAKE NOTICE, that {name} _______, is filing his/her
Child Support Guidelines Worksheet attached and labeled Exhibit 1.
CERTIFICATE OF SERVICE
I certify that a copy of this Notice of Filing with the Child Support Guidelines Worksheet was
[check all used]: ( ) 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: _________________________
E-mail Address(es): _____________________
Signature of Party or his/her Attorney
Printed Name: _________________________
Address: ____________________________
City, State, Zip: _______________________
Fax Number: _________________________
E-mail Address(es): _____________________
Florida Bar Number: ____________________
Florida Family Law Rules of Procedure Form 12.902(e), Child Support Guidelines Worksheet (09/12)
CHILD SUPPORT GUIDELINES WORKSHEET
A. FATHER
B. MOTHER
TOTAL
1. Present Net Monthly Income
Enter the amount from line 27, Section I of
Florida Family Law Rules of Procedure Form
12.902(b) or (c), Financial Affidavit.
2. Basic Monthly Obligation
There is (are) {number}_____ minor child(ren)
common to the parties.
Using the total amount from line 1, enter the
appropriate amount from the child support
guidelines chart.
3. Percent of Financial Responsibility
Divide the amount on line 1A by the total
amount on line 1 to get Father’s percentage of
financial responsibility. Enter answer on line 3A.
Divide the amount on line 1B by the total
amount on line 1 to get Mother’s percentage of
financial responsibility. Enter answer on line 3B.
%
%
4. Share of Basic Monthly Obligation
Multiply the number on line 2 by the
percentage on line 3A to get Father’s share
of basic obligation. Enter answer on line 4A.
Multiply the number on line 2 by the
percentage on line 3B to get Mother’s share
of basic obligation. Enter answer on line 4B.
Additional Support — Health Insurance, Child Care & Other
5. a. 100% of Monthly Child Care Costs
[Child care costs should not exceed the level
required to provide quality care from a
licensed source. See section 61.30(7), Florida
Statutes, for more information.]
b. Total Monthly Child(ren)’s Health Insurance
Cost
[This is only amounts actually paid for
health insurance on the child(ren).]
Florida Family Law Rules of Procedure Form 12.902(e), Child Support Guidelines Worksheet (09/12)
CHILD SUPPORT GUIDELINES WORKSHEET
A. FATHER
B. MOTHER
TOTAL
c. Total Monthly Child(ren)’s Noncovered
Medical, Dental and Prescription
Medication Costs
d. Total Monthly Child Care & Health Costs
[Add lines 5a + 5b +5c].
6. Additional Support Payments
Multiply the number on line 5d by the
percentage on line 3A to determine the Father’s
share. Enter answer on line 6A. Multiply the
number on line 5d by the percentage on line 3B
to determine the Mother’s share.
Enter answer on line 6B.
Statutory Adjustments/Credits
7. a. Monthly child care payments actually made
b. Monthly health insurance payments actually
made
c. Other payments/credits actually made for
any noncovered medical, dental and
prescription medication expenses of the
child(ren) not ordered to be separately paid
on a percentage basis.
(See section 61.30 (8), Florida Statutes)
8. Total Support Payments actually made
(
Add 7a thou
g
h 7c
)
9. MINIMUM CHILD SUPPORT OBLIGATION FOR
EACH PARENT
[Line 4 plus line 6; minus line 8]
Substantial Time-Sharing (GROSS UP METHOD) If each parent exercises time-sharing at least 20
percent of the overnights in the year (73 overnights in the year), complete Nos. 10 through 21
A. FATHER B. MOTHER TOTAL
10. Basic Monthly Obligation x 150%
[Multiply line 2 by 1.5]
Florida Family Law Rules of Procedure Form 12.902(e), Child Support Guidelines Worksheet (09/12)
CHILD SUPPORT GUIDELINES WORKSHEET
A. FATHER
B. MOTHER
TOTAL
11. Increased Basic Obligation for each parent.
Multiply the number on line 10 by the
percentage on line 3A to determine the
Father’s share. Enter answer on line 11A.
Multiply the number on line 10 by the
percentage on line 3B to determine the
Mother’s share. Enter answer on line 11B.
12. Percentage of overnight stays with each parent.
The child(ren) spend(s) ______overnight stays
with the Father each year. Using the number
on the above line, multiply it by 100 and divide
by 365. Enter this number on line 12A.
The child(ren) spend(s) _____ overnight stays
with the Mother each year. Using the number
on the above line, multiply it by 100 and divide
by 365. Enter this number on line 12B.
%
%
13. Parent’s support multiplied by other Parent’s
percentage of overnights.
[Multiply line 11A by line 12B. Enter this
number in 13A. Multiply line 11B by line 12A.
Enter this number in 13B.]
Additional Support — Health Insurance, Child Care & Other
14. a. Total Monthly Child Care Costs
[Child care costs should not exceed the level
required to provide quality care from a
licensed source. See section 61.30(7),
Florida Statutes, for more information.]
b. Total Monthly Child(ren)’s Health Insurance
Cost
[This is only amounts actually paid for health
insurance on the child(ren).]
c. Total Monthly Child(ren)’s Noncovered
Medical, Dental and Prescription
Medication Costs.
d. Total Monthly Child Care & Health Costs
[Add lines 14a + 14b + 14c.]
Florida Family Law Rules of Procedure Form 12.902(e), Child Support Guidelines Worksheet (09/12)
CHILD SUPPORT GUIDELINES WORKSHEET
A. FATHER
B. MOTHER
TOTAL
15. Additional Support Payments.
Multiply the number on line 14d by the
percentage on line 3A to determine the
Father’s share. Enter answer on line 15A.
Multiply the number on line 14d by the
percentage on line 3B to determine the
Mother’s share. Enter answer on line 15B.
Statutory Adjustments/Credits
16. a. Monthly child care payments actually
made
b. Monthly health insurance payments
actually made
c. Other payments/credits actually made
for any noncovered medical, dental and
prescription medication expenses of the
child(ren) not ordered to be separately
paid on a percentage basis.
[See section 61.30(8), Florida Statutes]
17. Total Support Payments actually made
[Add 16a though 16c]
18. Total Additional Support Transfer Amount
[Line 15 minus line 17; enter any negative
number as zero)
19. Total Child Support Owed from Father to
Mother [Add line 13A
p
lus line 18A]
20. Total Child Support Owed from Mother to
Father [Add line 13B plus line 18B]
21. Actual Child Support to Be Paid.
[Comparing lines 19 and 20, Subtract the
smaller amount owed from the larger amount
owed and enter the result in the column for
the parent that owes the larger amount of
support]
$
ADJUSTMENTS TO GUIDELINES AMOUNT. If you or the other parent is requesting the Court to award a
child support amount that is more or less than the child support guidelines, you must complete and file
Motion to Deviate from Child Support Guidelines, Florida Supreme Court Approved Family Law Form
12.943.
Florida Family Law Rules of Procedure Form 12.902(e), Child Support Guidelines Worksheet (09/12)
[check one only]
a. ____ Deviation from the guidelines amount is requested. The Motion to Deviate from Child
Support Guidelines, Florida Supreme Court Approved Family Law Form 12.943, is attached.
b. ____ Deviation from the guidelines amount is NOT requested. The Motion to Deviate from
Child Support Guidelines, Florida Supreme Court Approved Family Law Form 12.943, is not
attached.
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} ,______ {telephone number}________________________.
Instructions for Florida Supreme Court Approved Family Law Form 12.995(a), Parenting Plan (02/18)
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.995(a),
PARENTING PLAN (02/18)
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. The parents must identify a name or designation to be used
throughout this Parenting Plan.
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
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
Instructions for Florida Supreme Court Approved Family Law Form 12.995(a), Parenting Plan (02/18)
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.
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, and the instructions for the petition
and/or answer that were filed in this case.
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:
Instructions for Florida Supreme Court Approved Family Law Form 12.995(a), Parenting Plan (02/18)
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 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
Instructions for Florida Supreme Court Approved Family Law Form 12.995(a), Parenting Plan (02/18)
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.
Florida Supreme Court Approved Family Law Form 12.995(a), Parenting Plan (02/18)
IN THE CIRCUIT COURT OF THE _____________________ JUDICIAL CIRCUIT
IN AND FOR _________________ COUNTY, FLORIDA
Case No: _____________________
Division: _____________________
_______________________________
Petitioner,
and
______________________________
Respondent.
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
Petitioner, hereinafter referred to in this Parenting Plan as Parent
{name or designation} ___________________________________________________
Name:__________________________________________________________________
Address: ________________________________________________________________
Telephone Number: __________________E-Mail: _______________________________
_____ Address Unknown: {Please indicate here if Petitioner’s address is unknown}
_____ Address Confidential: {Please indicate here if Petitioner’s address and phone numbers are
confidential pursuant to either a _____ Final Judgment for Protection Against Domestic Violence,
or _____ other court order ______________________________________}.
Respondent, hereinafter referred to in this Parenting Plan as Parent
{name or designation} _________________________________________________________
Name:__________________________________________________________________
Florida Supreme Court Approved Family Law Form 12.995(a), Parenting Plan (02/18)
Address: ________________________________________________________________
Telephone Number: _________________ E-Mail: ________________________________
_____ Address Unknown: {Please indicate here if Respondent’s address is unknown}
_____ Address Confidential: {Please indicate here if Respondent’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
{Insert the name or designation of the appropriate parent in the space provided.}
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. Either parent may consent to mental health
treatment for the child(ren).
OR
Florida Supreme Court Approved Family Law Form 12.995(a), Parenting Plan (02/18)
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 Parent ______________
Non-emergency health care Parent ______________
Other: {Specify}______________ Parent ________________
___________________________ Parent ________________
___________________________ Parent _______________
OR
c._____ Sole Parental Responsibility:
It is in the best interests of the child(ren) that Parent {name or designation}
____________________ shall have sole authority to make major decisions for the
child(ren.) It is detrimental to the child(ren) to have shared parental responsibility.
2. 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.
3. Extra-curricular Activities {Indicate all that apply}
{Insert the name or designation of the appropriate parent in the space provided.
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:
Parent __________________ ______%
Parent __________________ ________ %
e._____ The uniforms and equipment required for the extra-curricular activities shall be paid
by:
Parent __________________ _______ %
Parent __________________ ________%
Florida Supreme Court Approved Family Law Form 12.995(a), Parenting Plan (02/18)
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.
The parents shall follow the school calendar of: {Indicate all that apply}
a._____the oldest child
b._____the youngest child
c.______________________ County
Florida Supreme Court Approved Family Law Form 12.995(a), Parenting Plan (02/18)
d.______________________ 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 {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
{Insert the name or designation of the appropriate parent in the space provided.}
{A time-sharing schedule must be provided for both parents.}
1. Weekday and Weekend Schedule
The following schedule shall apply beginning on ________________________ with
Parent {name or designation}_________________________ and continue as follows:
The child(ren) shall spend time with Parent _______________ 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 Parent _______________ on the following
dates and times:
WEEKENDS: _____ Every _____ Every Other _____ Other {specify}______________
From____________________________ to _________________________________
WEEKDAYS: {Specify days} ______________________________________________
From _____________________________ to _______________________________
OTHER: {Specify} _____________________________________________________
___________________________________________________________________
Florida Supreme Court Approved Family Law Form 12.995(a), Parenting Plan (02/18)
___________________________________________________________________.
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 the name or designation of the appropriate parent 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 _______ __________ __________ _____________
4
th
of July __________ _________ __________ _____________
Labor Day Wkd __________ _________ __________ _____________
Columbus Day Wkd _______ _________ __________ _____________
Halloween __________ _________ __________ _____________
Thanksgiving __________ _________ __________ _____________
Veteran’s Day __________ _________ __________ _____________
Hanukkah __________ _________ __________ _____________
Yom Kippur __________ _________ __________ _____________
Rosh Hashanah __________ _________ __________ _____________
Child(ren)’s
Birthdays: __________ _________ __________ _____________
Florida Supreme Court Approved Family Law Form 12.995(a), Parenting Plan (02/18)
__________ __________ _________ __________ _____________
__________ __________ _________ __________ _____________
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}
{Insert the name or designation of the appropriate parent in the space provided.}
a. _____Parent__________________ 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._____ Parent ______________________ 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:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________.
4. Spring Break {Choose only one}
{Insert the name or designation of the appropriate parent in the space provided.}
a. _____ The parents shall follow the regular schedule.
Florida Supreme Court Approved Family Law Form 12.995(a), Parenting Plan (02/18)
b. _____The parents shall alternate the entire Spring Break with Parent
________________having the child(ren) during the _____odd-numbered years
and Parent _______________ during the _____even numbered years.
c._____Parent _______________ _____ Parent ________________ 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}_______________________________________.
5. Summer Break {Choose only one}
{Insert the name or designation of the appropriate parent in the space provided.}
a. _____The parents shall follow the regular schedule through the summer.
b._____ Parent _________________ 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, _____Parent _______
_______ _____ Parent ______________ 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:
{Insert the name or designation of the appropriate parent in the space provided.}
Based upon the time-sharing schedule, Parent ________________ has a total of _____
overnights per year and Parent ________________ 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)
Florida Supreme Court Approved Family Law Form 12.995(a), Parenting Plan (02/18)
{Insert the name or designation of the appropriate parent in the space provided.}
1. Transportation {Choose only one}
a.____ Parent ______________ shall provide all transportation.
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 the parents’ 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}
{Insert the name or designation of the appropriate parent in the space provided.}
a. _____Transportation costs are included in the Child Support Worksheets and/or the
Order for Child Support and should not be included here.
b._____Parent _____________ shall pay ______% and Parent __________________
shall pay ______ % of the transportation costs.
c. _____Other: ___________________________________________________________.
Florida Supreme Court Approved Family Law Form 12.995(a), Parenting Plan (02/18)
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 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 address of
Parent {name or designation} _______________________ shall be used .
2. _____ {If Applicable} The following provisions are made regarding private or home
schooling: ___________________________________________________________
_____________________________________________________________________
_____________________________________________________________________.
3. Other. ________________________________________________________________
____________________________________________________________________
____________________________________________________________________.
X. DESIGNATION FOR OTHER LEGAL PURPOSES
{Insert the name or designation of the appropriate parent in the space provided.}
The child(ren) named in this Parenting Plan are scheduled to reside the majority of the time with
Parent __________________ . 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.
Florida Supreme Court Approved Family Law Form 12.995(a), Parenting Plan (02/18)
XI. 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}_________________________________________.
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}
1. _____Each parent may select appropriate child care providers
Florida Supreme Court Approved Family Law Form 12.995(a), Parenting Plan (02/18)
2. _____All child care providers must be agreed upon by both parents.
3. _____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.
4. _____Other: {Specify}__________________________________________________.
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
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________.
Florida Supreme Court Approved Family Law Form 12.995(a), Parenting Plan (02/18)
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 Petitioner/Parent ______________
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 12.995(a), Parenting Plan (02/18)
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 Respondent/Parent ____________
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} ____________.
Instructions for Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan
(02/18)
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.995(b),
SUPERVISED/SAFETY-FOCUSED PARENTING PLAN
(02/18)
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.
The parents must identify a name or designation to be used throughout this Parenting Plan.
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
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
Instructions for Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan
(02/18)
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.
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, and the instructions for the petition
and/or answer that were filed in this case.
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).
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
Instructions for Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan
(02/18)
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 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;
Instructions for Florida Supreme Court Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan
(02/18)
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
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.
Florida Supreme Court Approved Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan
(02/18)
IN THE CIRCUIT COURT OF THE ______ JUDICIAL CIRCUIT
IN AND FOR ________________________ COUNTY, FLORIDA
Case No: _____________________
Division: _____________________
_______________________________
Petitioner,
and
_______________________________
Respondent.
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
Petitioner, hereafter referred to in this Parenting Plan as Parent
{name or designation} __________________________________________________
Name:__________________________________________________________________
Address:________________________________________________________________
Telephone Number:___________________E-Mail:_________________________________
_____ Address Unknown: {Please indicate if Petitioner’s address is unknown}
_____ Address Confidential: {Please indicate if Petitioner’s address and phone numbers are
confidential pursuant to either a _____ Final Judgment for Protection Against Domestic Violence
or _____ other court order _____________________________________________.}
Respondent, hereafter referred to in this Parenting Plan as Parent
{name or designation} ___________________________________________________
Name:__________________________________________________________________
Address:________________________________________________________________
Florida Supreme Court Approved Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan
(02/18)
Telephone Number: _________________ E-Mail: _____________________________________
_____ Address Unknown: (Please indicate if Respondent’s address is unknown}
_____ Address Confidential: (Please indicate if Respondent’s address and telephone
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. 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}
{Insert the name or designation of the appropriate parent in the space provided.}
1. _____ Sole Parental Responsibility
It is in the best interests of the child(ren) that Parent
{name or designation} _____________________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.
OR
2. _____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:
Florida Supreme Court Approved Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan
(02/18)
Education/Academic decisions Parent ______________
Non-emergency health care Parent ______________
________________________ Parent ______________ ______
________________________ Parent _____________ ______
_________________________ Parent ______________
_____Other: {Specify}___________________________________________.
V. TIME-SHARING SCHEDULE {Choose only one}
{Insert the name or designation of the appropriate parent in the space provided}
1.______No Time-Sharing: Parent ______________________ shall have no contact with
the child(ren) until further order of the court. All parenting decisions shall be made by
the other parent.
2. _____Supervised Time-Sharing: Whenever the child(ren) are with ________Parent
___________________, the supervisor shall be present .______Parent ____________
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}
a. _____hours per week. The place(s), and time(s) shall be set by Parent
____________.
b. _____ From ___ m. to ____m. on the following day(s) ______________________
_____________________________________________________________________.
3. _____ Restricted Time-Sharing: _____Parent __________________ 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:_______________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________.
a._______ hours per week. The place(s), and time(s) shall be set by Parent
__________
b. ______Other: _______________________________________________________.
Florida Supreme Court Approved Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan
(02/18)
VI. SUPERVISOR AND SUPERVISION {Choose only one}
{Insert the name or designation of the appropriate parent in the space provided.}
1. Supervisor. The person supervising the time-sharing shall be selected by: {Choose only one}
_____ both parents .
_____ Parent {name or designation} ____________________, 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 Parent
{name or designation} __________________________________.
_____Other: ______________________________________________________.
VII. LOCATION: {Choose only one}
{Insert the name or designation of the appropriate parent in the space provided.}
_____Parent_________________________ _____ Parent ______________________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 Parent ______________
3._____ Any location designated by Parent ____________________ with the approval of the
supervisor.
4._____ Other: _____________________________________________________ .
VIII. DESIGNATION FOR OTHER LEGAL PURPOSES
{Insert the name or designation of the appropriate parent in the space provided.}
Florida Supreme Court Approved Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan
(02/18)
1. The child(ren) named in this Safety-Focused Parenting Plan are scheduled to reside the
majority of the time with Parent {name or designation} ______________________________.
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 address of Parent {name
or designation} ____________________shall be used.
IX. TRANSPORTATION AND EXCHANGE OF CHILD(REN)
{Insert the name or designation of the appropriate parent in the space provided.}
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.
Parent ____________ Parent ______________ 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}
a. _____ Parent ________________ with the supervisor present.
b. _____ The supervisor alone.
c. ____ Other: _______________________________________________.
2. Exchange
{Insert the name or designation of the appropriate parent in the space provided.}
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. Parent ___________________ is prohibited from coming to the exchange point.
X. COMMUNICATION
1. Between Parents
Florida Supreme Court Approved Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan
(02/18)
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] ___________________________________________.
_____ 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)
{Insert the name or designation of the appropriate parent in the space provided.}
Parent {name or designation} __________________ {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.
Florida Supreme Court Approved Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan
(02/18)
The costs of electronic communication shall be addressed as follows:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________.
XI. ACCESS TO ACTIVITIES AND EVENTS
{Insert the name or designation of the appropriate parent in the space provided.}
______Parent ______________________ {Choose only one}
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._____ Must stay ______ feet from the other parent and ______ feet from the child.
4._____ Other _______________________________________________.
XII. CHILD(REN)’S SAFETY
{Insert the name or designation of the appropriate parent in the space provided.}
______Parent {name or designation} ______________________ 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.
Florida Supreme Court Approved Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan
(02/18)
XIV. OTHER PROVISIONS
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________.
Florida Supreme Court Approved Family Law Form 12.995(b), Supervised/Safety-Focused Parenting Plan
(02/18)
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 Petitioner/Parent ____________________
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 12.995(b), Supervised/Safety-Focused Parenting Plan
(02/18)
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 Respondent/Parent ___________________
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 12.994(a)(2), Final Judgment for Support and Parenting Plan
Unconnected with Dissolution of Marriage (02/18)
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FOR COUNTY, FLORIDA
Case No.:
Division:
In Re: the Marriage of:
,
Petitioner,
and
,
Respondent.
FINAL JUDGMENT FOR SUPPORT AND PARENTING PLAN
UNCONNECTED WITH DISSOLUTION OF MARRIAGE
WITH DEPENDENT OR MINOR CHILD(REN)
This cause came before this Court on a Petition for Support and Parenting Plan 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
A. _____ The Court denies the request for alimony;
OR
Florida Supreme Court Approved Family Law Form 12.994(a)(2), Final Judgment for Support and Parenting Plan
Unconnected with Dissolution of Marriage (02/18)
B. _____The Court finds that that there is a need for alimony and that the _____ Petitioner
_____Respondent has/had the ability to support his/her spouse and has failed to do so.
_____Petitioner _____ Respondent (hereinafter Obligor) has the present ability to pay alimony as
follows: {Indicate all that apply}
1. ______ Permanent Periodic.
a. The court finds that no other form of alimony is fair and reasonable under the
circumstances of the parties.
b. 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:_________________________________
_______________________________________________________________
_______________________________________________________________.
c. 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.
2. _______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.
3. _____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}
Florida Supreme Court Approved Family Law Form 12.994(a)(2), Final Judgment for Support and Parenting Plan
Unconnected with Dissolution of Marriage (02/18)
_____________________________________________________________________,
whichever occurs first. The rehabilitative plan presented demonstrated the following:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________.
4. __ ___Durational. Obligor shall pay durational alimony to Obligee in the amount of
$____________ permonth, 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
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.
5. _____ Lump Sum. Obligor shall pay lump sum alimony to Obligee in the amount of
$_________ which shall be paid as
follows:____________________________________________.
6. _____ Retroactive. Obligor shall pay retroactive alimony in the amount of $_________
for the period of {date} , through {date} , which
shall be paid pursuant to paragraph D. below.
C. Reasons for _____ Awarding _____ Denying Alimony. The Court has considered all of the
following in awarding/denying alimony:
1. The standard of living established during the marriage;
2. The duration of the marriage;
3. The age and the physical and emotional condition of each party;
4. The financial resources of each party, including the nonmarital and marital assets and
liabilities distributed to each;
5. 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;
6. 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;
7. The responsibilities each party will have with regard to any minor or dependent
children they have in common;
8. 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;
9. All sources of income available to either party, including income available to either
party through investments of any asset held by that party and
10. Any other factor necessary to do equity and justice between the parties: {explain}
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.
_______ Please indicate here if additional pages are attached.
Florida Supreme Court Approved Family Law Form 12.994(a)(2), Final Judgment for Support and Parenting Plan
Unconnected with Dissolution of Marriage (02/18)
D. Retroactive Alimony and/or Arrearages.
1. _____There is no alimony arrearage at the time of this Final Judgment.
OR
2. _____Petitioner _____ Respondent shall pay to the other party alimony in the
amount of:
$ for retroactive alimony, as of {date} ____ .
$ for previously ordered unpaid alimony, as of {date} .
The total of $ ___ in retroactive alimony and arrearages 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 or _____ other {explain} ___________
beginning {date __________, until paid in full including statutory interest.
E. ._____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.
F. _____ Other provisions relating to alimony including any tax treatment and consequences:
1. The award of alimony _____ does not _____ does leave the Obligor with significantly 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: _______________________________________
____________________________________________________________________
_____________________________________________________________________
______________________________________________________________________.
2. Other:__________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________.
SECTION II. PARENTING PLAN ESTABLISHING PARENTAL RESPONSIBILITY AND TIME-SHARING WITH
DEPENDENT OR MINOR CHILD(REN)
A. 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.
B. The parties’ dependent or minor child(ren) is (are):
Florida Supreme Court Approved Family Law Form 12.994(a)(2), Final Judgment for Support and Parenting Plan
Unconnected with Dissolution of Marriage (02/18)
Name Birth date
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
C. Parenting Plan. The parties shall comply with the Parenting Plan which is attached and
incorporated herein as Exhibit _______.
SECTION III. CHILD SUPPORT
A. ______The Court finds that there is a need for child support and that the _____ Petitioner
______ Respondent (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 _____ Petitioner _____Respondent are correct
OR
_____the Court makes the following findings:
Petitioner’s net monthly income is $ ___________, (Child Support Guidelines _ %).
Respondent’s net monthly income is $ ____, (Child Support Guidelines _____%).
Monthly child care costs are $ _.
Monthly health/dental insurance costs are $ ____________.
B. 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’ 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.}
Florida Supreme Court Approved Family Law Form 12.994(a)(2), Final Judgment for Support and Parenting Plan
Unconnected with Dissolution of Marriage (02/18)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.
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:
.
C. Retroactive Child Support and/or Arrearages.
1. ____ There is no retroactive child support or child support arrearage at the time of this Final
Judgment.
OR
2. _____ The _____ Petitioner _____ Respondent shall pay to the other party child support in
the amount of:
$_____________for retroactive child support, as of {date}____________________________;
$ ___________ _ for previously ordered unpaid child support, as of {date} __________________
The total of $ __________ of retroactive child support and arrearages 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 or_____ other {explain} _______________
beginning {date} _________, until paid in full including statutory interest.
D. Insurance.
{Indicate all that apply}
1. Health/Dental Insurance. _____ Petitioner _____ Respondent 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
Florida Supreme Court Approved Family Law Form 12.994(a)(2), Final Judgment for Support and Parenting Plan
Unconnected with Dissolution of Marriage (02/18)
_____ Health _____ Dental insurance is either not reasonable in cost or accessible to the
children at this time.
2. _____ 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.
E. _____Life Insurance (to secure payment of support). To secure the child support obligations in
this judgment, _____ Petitioner _____Respondent ______ 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 _____ Petitioner _____ Respondent
_____ 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.
F. 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.
G. Other provisions relating to child support:
______________________________________________________________________________
SECTION IV. METHOD OF PAYMENT
Obligor shall pay court-ordered child support/alimony and arrears, if any, as follows:
A. Place of Payment.
1._____ 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.
2._____ Both parties have requested and the court finds that it is in the best interests of the
Florida Supreme Court Approved Family Law Form 12.994(a)(2), Final Judgment for Support and Parenting Plan
Unconnected with Dissolution of Marriage (02/18)
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.
B. Income Deduction.
1_____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.
2._____ 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.
C. 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.
D. Other provisions relating to method of payment.
______________________________________________________________________________
.
SECTION V. 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
Florida Supreme Court Approved Family Law Form 12.994(a)(2), Final Judgment for Support and Parenting Plan
Unconnected with Dissolution of Marriage (02/18)
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’s fees, costs, and suit money are as follows:
__________________________________________________________________________________
__________________________________________________________________________________
.
SECTION VI. OTHER PROVISIONS
A. Other Provisions: _______________________________________________________________
B. The Court reserves jurisdiction to modify and enforce this Final Judgment.
DONE AND ORDERED in _____, Florida, on _______________________ .
CIRCUIT JUDGE
I certify that a copy of this Final Judgment for Support and Parenting Plan Unconnected with Dissolution
of Marriage with Dependent or Minor Child(ren) 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/her attorney)
_____Respondent (or his/her attorney)
_____Central Depository
_____State Disbursement Unit
_____Other:
Florida Supreme Court Approved Family Law Form 12.994(a)(2), Final Judgment for Support and Parenting Plan
Unconnected with Dissolution of Marriage (02/18)
Instructions for Florida Supreme Court Approved Family Law Form 12.923, Notice of Hearing
(General) (11/15)
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.923,
NOTICE OF HEARING (GENERAL) (11/15)
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.
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
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 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
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 12.923, Notice of Hearing
(General) (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.
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.
Florida Supreme Court Approved Family Law Form 12.923, Notice of Hearing (General) (11/15)
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:
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.
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.
Florida Supreme Court Approved Family Law Form 12.923, Notice of Hearing (General) (11/15)
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): __________________
____________________________________________
_______
Signature of Party
Printed Name: _________________________________
Address: ______________________________________
City, State, Zip: _________________________________
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} ________________
Instructions for Florida Supreme Court Approved Family Law Form 12.924, Notice for Trial (11/15)
INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW
FORM 12.924, NOTICE FOR TRIAL (11/15)
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.
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.
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.
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.
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
Instructions for Florida Supreme Court Approved Family Law Form 12.924, Notice for Trial (11/15)
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.
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...
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.
Florida Supreme Court Approved Family Law Form 12.924, Notice for Trial (11/15)
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 ( ) 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): __________________
____________________________________________
_______
Signature of Party
Printed Name: _________________________________
Address: ______________________________________
City, State, Zip: _________________________________
Fax Number: ___________________________________
Designated E-mail Address(es): ____________________
_____________________________________________
Florida Supreme Court Approved Family Law Form 12.924, Notice for Trial (11/15)
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} ________________
Instructions for Florida Family Law Rules of Procedure Form 12.999, Final Disposition Form (03/17)
INSTRUCTIONS FOR FLORIDA FAMILY LAW RULES OF PROCEDURE
FORM 12.999
FINAL DISPOSITION FORM
(03/17)
When should this form be used?
This form is filed by the petitioner or respondent for the use of the clerk of the court for the purpose of
reporting judicial workload data under section 25.075, Florida Statutes. When your case is completed, the
petitioner or respondent must complete this form and file it with the clerk.
What should I do next?
This form must be typed or printed in black ink. After completing and signing this form, you should then file it
and keep a copy for your records.
A copy of this form must be e-mailed, mailed, or hand delivered to the other party(ies) in your case.
Instructions for completing this form
I. Case Style. Enter the name of the court, the case number assigned at the time of the filing of the
petition, counterpetition, or motion, the name of the judge assigned, and the names of the petitioner and
respondent.
II. Means of Final Disposition. Place an “x” on the appropriate line before the major category and the
appropriate subcategory, if applicable. The following are the definitions of the disposition categories.
A. Dismissed Before Hearing or Trial. The case is settled, voluntarily dismissed, or otherwise
disposed of before a hearing or trial is held.
B. Dismissed Under Settlement, Before Hearing or Trial. Before hearing or trial, the case is
voluntarily dismissed by the petitioner, respondent, or movant after a settlement.
C. Dismissal Under Mediated Settlement, Before Hearing or Trial. The case is voluntarily dismissed
by the petitioner or respondent after a settlement is reached with mediation before a hearing
or trial is held.
D. Other, Before Hearing or Trial. The case is dismissed before a hearing or trial in an action that
does not fall into one of the other disposition categories on this form.
E. Dismissal Before Hearing or Trial. The case is dismissed by a judge voluntarily after a hearing or
trial is held.
Instructions for Florida Family Law Rules of Procedure Form 12.999, Final Disposition Form (03/17)
F. Dismissed Under a Settlement, After Hearing or Trial. The case is voluntarily dismissed by the
petitioner, respondent, or movant after a settlement is reached without mediation after a
hearing or trial is held.
G. Dismissal Under a Mediated Settlement, After Hearing or Trial. The case is voluntarily dismissed
by the petitioner, respondent, or movant after a settlement is reached with mediation after a
hearing or trial.
H. Other, After Hearing or Trial. The case is dismissed after hearing in an action that does not fall
into the categories listed on this form.
I. Disposed by Default. A respondent chooses not to or fails to contest the petitioner’s allegations
and a judgment against the respondent is entered by the court.
J. Disposed by Judge. A judgment or disposition is reached by the judge in a case that is not
dismissed and in which no trial has been held. Includes stipulations by the parties, conditional
judgments, summary judgment after hearing, and any manner in which a judgment is entered,
excluding cases disposed of by default as in category I. above.
K. Disposed by Nonjury Trial. The case is disposed as a result of a contested trial in which there is
no jury and in which the judge determines both the issues of fact and the law in the case.
L. Disposed by Jury Trial. Any part of the case is disposed as a result of a jury trial (considered the
beginning of a jury trial to be when the jurors and alternates are selected and sworn).
M. Other. The case is consolidated, submitted to mediation or arbitration, transferred, or
otherwise disposed of by any other means not listed in categories (A) to (L).
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.
Florida Family Law Rules of Procedure Form 12.999, Final Disposition Form (03/17)
FINAL DISPOSITION FORM
I. Case Style
{Name of Court} __________________________________
{Petitioner} {Case number}
{Judge} _________________________
{Respondent}
II. Means of Final Disposition
Place an “x” on the line for the major category and one subcategory, f applicable only.
Dismissed before hearing/trial
Dismissed pursuant to settlement, before hearing or trial
Dismissed under a mediated settlement before hearing or trial
Other, before hearing or trial
Dismissed after hearing or trial
_ Dismissed pursuant to a settlement, after hearing or trial
_ Dismissed pursuant to a mediated settlement, after hearing or trial
_ Other after hearing or trial
Disposed by default
Disposed by judge
Disposed by nonjury trial
Disposed by jury trial
Other {specify} .
Date: ________________________
Signature of Attorney or Party
Printed Name:
Address:
City, State, Zip:
Telephone Number:
E-mail address(es):
Fax number:
Florida Family Law Rules of Procedure Form 12.999, Final Disposition Form (03/17)
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} _________, {telephone number} .
Sixth Judicial Circuit Local Form-Motion to/for 10-13-2000 Page 1 of 2
Forms for use with:
Motion to/for
Instructions for Sixth Judicial Circuit Local Form, Motion to/for 12-2002
INSTRUCTIONS FOR
MOTION TO/FOR________________
Before a Judge (or in certain instances, a General Master/Hearing Officer) can hear your
case, you must first put in writing what
you are asking the Court to do and why. Usually this is
done in the form of a Motion. Some examples of Motions you might file are:
Motion to Compel Discovery
Motion to Continue
Motion to Clarify
Motion for Contempt*
Once you have filled out the Motion, (see attached example) you must file the original
with the Clerk of Court and mail a copy to the other party in your case. If the other party has an
attorney, you should mail a copy to the attorney instead. You must schedule your Motion for a
Hearing before the assigned Judge or a General Master/Hearing Officer. You must coordinate a
mutually agreeable time and date for the Hearing, and give no less than 5 (five) working days
advance Notice of Hearing to the opposing party or attorney, in writing. See the Instructions to
the “Notice of Hearing” forms to learn more about how to schedule your case for a Hearing.
*If this Motion is filed after a Final Judgment has been entered:
(1) the Motion should be set for Hearing before a General Master.
(2) the Motion should not
be used to modify any provisions of a Final Judgment.
Instead, a Supplemental Petition must be filed.
Sixth Judicial Circuit Local Form, Motion Example 12-2002 Page 1 of 2
MOTION EXAMPLE
IN THE CIRCUIT COURT OF THE 6
TH
JUDICIAL CIRCUIT, IN
AND FOR (county name, where case is filed) COUNTY, FLORIDA
REF:_(your pinellas/pasco county case number)
UCN:_(your statewide unform case number)
Division: (court division of your case)
(The name of the person who filed the case originally) ,
Petitioner,
and
(The name of the other party in this case)
,
Respondent.
_____________________________________________/
MOTION TO/FOR: (What you are asking for)
(Your name), respectfully moves this Honorable Court to grant this Motion to/for
(What you are asking for), and as grounds therefore would show:
1.(Why you think you should get what you are asking for
)
2._____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
3.____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
4.____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a copy hereof has been furnished by mail/hand
delivery/personal service to the persons listed below this _____ day of _____________, 20___.
Party or their attorney(if represented)
Other
Name______________________________ Name______________________________
Address____________________________ Address____________________________
___________________________________ __________________________________
City State Zip City State Zip
Telephone No._______________________ Telephone No._______________________
Telefax No._________________________ Telefax No._________________________
DATED:____________________________
* The below section must be completed. Here you are certifying that you have provided a copy of your
pleadings to the other party, and how you did so.
THIS SECTION MUST NOT BE LEFT BLANK OR INCOMPLETE.
Sixth Judicial Circuit Local Form, Motion Example 12-2002 Page 2 of 2
________________________________________
Signature of party signing certificate and pleading
Printed name_____________________________
Address_________________________________
________________________________________
City State Zip
________________________________________
Telephone (area code and number)
________________________________________
Telefax (area code and number)
* This section must be completed by you. All pleadings must be signed. A return address or p.o.
box is required.
Sixth Judicial Circuit Local Form, Motion to/for 12-2002 Page 1 of 2
IN THE CIRCUIT COURT OF THE ______ JUDICIAL CIRCUIT, IN
AND FOR _____________COUNTY, FLORIDA
REF:_____________________________
UCN:_____________________________
Division:__________________________
,
Petitioner,
and
,
Respondent.
_________________________________________/
MOTION TO/FOR:
________________________, respectfully moves this Honorable Court to grant
this Motion to/for _________________________, and as grounds therefore would show:
1.
___________________________________________________________
__________________________________________________________________
__________________________________________________________________
2. ___________________________________________________________
__________________________________________________________________
__________________________________________________________________
3. _____________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4.___________________________________________________________
_________________________________________________________________
__________________________________________________________________
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a copy hereof has been furnished by mail/hand
delivery/personal service to the persons listed below this _____ day of ______________, 20___.
Party or their attorney(if represented)
Other
Name______________________________ Name_______________________________
Address____________________________ Address_____________________________
___________________________________ ____________________________________
City State Zip City State Zip
Telephone No._______________________ Telephone No.________________________
Telefax No._________________________ Telefax No.__________________________
DATED:____________________________
SIXTH
PINELLAS
Sixth Judicial Circuit Local Form, Motion Example 12-2002 Page 2 of 2
________________________________________
Signature of party signing certificate and pleading
Printed name_____________________________
Address_________________________________
________________________________________
City State Zip
________________________________________
Telephone (area code and number)
________________________________________
Telefax (area code and number)
IF A NONLAWYER HELPED YOU FILL OUT THIS FORM THEY MUST FILL IN
THE BLANKS BELOW:
I, (name of nonlawyer) ______________________________________, a nonlawyer, located at
(street)___________________________________(city)________________________(state)____
(phone)_________________, helped (name)__________________________, who is the
[check one only] ____petitioner or ____respondent, fill out this form.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
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Ken BurKe, C.P.A. www.mypinellasclerk.org (Pinellas County Clerk of the Circuit Court and Comptroller)

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Completed 10 February 2021

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