DH 5075, 04/2016, Florida Administrative Code Rule 64V-1.016 (Obsoletes Previous Editions)
State of Florida
Department of Health
Bureau of Vital Statistics
PETITION FOR TERMINATION OF PARENTAL RIGHTS
In accordance with Chapter 63.054(1), Florida Statute
(TYPE OR PRINT INFORMATION)
INFORMATION BELOW FOR USE BY VITAL STATISTICS
STATE OF FLORIDA
COUNTY: ____________________________ DOCKET OR FILE NUMBER: ___________________
NAME OF PERSONS WHOSE RIGHTS ARE SOUGHT TO BE TERMINATED:
______________________________________________________________________________________
______________________________________________________________________________________
DATE AND TIME PETITION FILED: ____________________________________________________
INFORMATION AS IT APPEARS ON FLORIDA BIRTH RECORD
CHILD’S FULL NAME: (As appears on Birth Certificate First, Middle, Last, Suffix):
______________________________________________________________________________________
DATE OF BIRTH (mm/dd/yyyy): _________________________
BIRTHPLACE (City/County): ____________________________________________________________
MOTHER’S / PARENT’S NAME PRIOR TO FIRST MARRIAGE (if applicable):
______________________________________________________________________________________
First Middle Last Suffix
FATHER’S / PARENT’S NAME OR ALLEGED NAME PRIOR TO FIRST MARRIAGE (if
applicable):
______________________________________________________________________________________
First Middle Last Suffix
SIGNED AND SEALED BY: ______________________________ ____________________
Signature of Clerk of Court Date Signed
