Temporary Custody

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INSTRUCTIONS TO FILE FOR TEMPORARY CUSTODY

● Extended Family Member requirements to file for the temporary custody of a minor
child:
An Extended Family Member is:
A relative of a minor child within the third degree by blood or marriage to the parent;
OR
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(ren)’s parents as an adverse party;
OR
An individual who qualifies as “fictive kin.” As defined in section 39.01, Florida Statutes, fictive kin
means a person unrelated by birth, marriage, or adoption who has an emotionally significant
relationship, which possesses the characteristics of a family relationship, to a child.

● Each parent must either consent (see Section I) or be served (see Sections II & III).

● If at any time before or after you file your case you decide that you no longer want to
represent yourself, you may hire a lawyer.

Table of Contents
I. If the Parent(s) Consent – Page 2
II. If You Know the Parent’(s) Address – Page 3
III. If You Do Not Know the Parent’(s) Address – Page 3
IV. Index of Forms

The Day of Your Self-Help Appointment on the 24th Floor

You MUST be on time for your scheduled appointment. If you are late, you
will be rescheduled for another date and charged a reschedule fee of $20.
Bring the following:
1. Completed forms in English and black ink (please type or print legibly!)
2. Pen (please use black ink only) (please type or print legibly!)
3. White correction tape or white correction fluid
4. Driver’s License, State ID, or U.S. Passport
5. Applicable Fees
6. Keep in mind the Clerk’s Office hours are from 9:00am to 4:00pm

Instructions – Temporary Custody page1

The Family Court Self-Help Program


Self Help File No.: packet_number Receipt & Packet No.: packet_number
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I. If the Parent(s) Consent

Step 1: Complete the following documents:

Petitioner
Petition for Temporary Custody [Form A-5]
Cover Sheet [Form H]
UCCJEA [FormJ]
Notice of Related Cases
Index of Forms (top portion only)
Acknowledgment of Receipt

Parent(s)
Consent for Temporary Custody and Waiver (one for each parent)
[Form L-4]
a. Each parent must complete a Consent for Temporary Custody
and Waiver. The consent must be signed, notarized and
witnessed by two people.
b. If only one parent will sign a Consent, the other parent must be
served. (See Section II or III)
c. For a deceased parent, a certified death certificate must be
attached to the Petition.

Step 2: Select one of the following options to have your packet reviewed by a Self-Help
Paralegal.
Option 1: Make your appointment online https://www.jud11.flcourts.org/Family-
Court-Self-Help-Program to review and notarize your documents. Please read the
Self-Help Appointment Review Options sheet before scheduling your
appointment online. We offer packet completion assistance at a nominal fee if you
need help completing your packet.

Option 2: Mail or Drop off your packet for review at either Self-Help location
without an appointment. Please read Self-Help Packet Review Via Mail sheet and
follow the instructions if you select this option.

After your packet has been reviewed and approved by a Self-Help Paralegal you
will receive further instructions regarding your next steps.

Instructions – Temporary Custody page 2

The Family Court Self-Help Program


Self Help File No.: packet_number Receipt & Packet No.: packet_number
Printed on: 4/19/2023 11:38:12 AM
II. If You Know the Parent’s Address
[For a Parent that does not sign a Consent]
Step 1: Complete the following documents:
a. Cover Sheet [Form H]
b. Petition for Temporary Custody [Form A-5]
c. Summons [Form G] – one for each parent that needs to be served.
d. Index of Forms (top portion only)
e. Acknowledgment of Receipt
f. Notice of Related Cases

Step 2: Select one of the following options to have your packet reviewed by a Self-Help
Paralegal.
Option 1: Make your appointment online https://www.jud11.flcourts.org/Family-
Court-Self-Help-Program to review and notarize your documents. Please read the
Self-Help Appointment Review Options sheet before scheduling your
appointment online. We offer packet completion assistance at a nominal fee if you
need help completing your packet.

Option 2: Mail or Drop off your packet for review at either Self-Help location
without an appointment. Please read Self-Help Packet Review Via Mail sheet and
follow the instructions if you select this option.

After your packet has been reviewed and approved by a Self-Help Paralegal you
will receive further instructions regarding your next steps.

Instructions – Temporary Custody page 3

The Family Court Self-Help Program


Self Help File No.: packet_number Receipt & Packet No.: packet_number
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III. If You Do Not Know the Parent’s Address
Step 1: Complete the following documents:
a. Cover Sheet [Form H]
b. Petition Awarding Temporary Custody [Form A-5]
c. Notice of Publication [Form D]
d. Affidavit of Diligent Search [Form C]
e. The three (3) Letters for Diligent Search of Natural Parent [Form B]
f. Affidavit of Search Inquiry on Relatives of Parent
g. Armed Services printed response to internet request whether respondent is
in the military.
h. Related Cases
i. Index of Forms
j. Acknowledgment of Receipt
k. Notice of Related Cases

Step 2: Select one of the following options to have your packet reviewed by a Self-Help
Paralegal. (Make sure diligent search process is completed prior to your appointment)

Option 1: Make your appointment online https://www.jud11.flcourts.org/Family-


Court-Self-Help-Program to review and notarize your documents. Please read the
Self-Help Appointment Review Options sheet before scheduling your
appointment online. We offer packet completion assistance at a nominal fee if you
need help completing your packet.

Option 2: Mail or Drop off your packet for review at either Self-Help location
without an appointment. Please read Self-Help Packet Review Via Mail sheet and
follow the instructions if you select this option.

After your packet has been reviewed and approved by a Self-Help Paralegal you
will receive further instructions regarding your next steps.

Fee Schedule
Self-Help Service Fee $85.00 cash, credit card or money order
Filing Fee $301.00 cash, credit card or money order
Issue Summons $ 10.00 cash, credit card or money order
Service Fee $ 40.00 per summons money order or cashier’s check
Publication Fee $35.00 per publication money order
3 Letter or Internet Search Fees………………..

Instructions – Temporary Custody page 4

The Family Court Self-Help Program


Self Help File No.: packet_number Receipt & Packet No.: packet_number
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SELF-HELP PARALEGAL APPOINTMENT REVIEW OPTIONS
The Eleventh Judicial Circuit’s Self-Help Program (SHP) provides Self-Represented
Litigants (SRL) two options to have your packet reviewed by a paralegal prior to
filing. Option 1 You can schedule an in-person appointment to have your packet
reviewed by our paralegal which can be scheduled online. Option 2. You can have
your packet reviewed by a paralegal without an appointment by simply dropping off
or mailing your packet at either Self-help location. Please read the different
appointment types carefully below before clicking on the link to schedule your
appointment or mailing your packet for review via mail without an appointment.

Please note that scheduling the incorrect appointment type can subject you to
being rescheduled for another date. All SHP appointments are scheduled for
specific dates and times depending on the appointment type. If you schedule your in-
person appointment online, you will receive a confirmation via email and text with
your appointment details. Please carefully read the details below regarding the
different appointment review types.

Paralegal Appointment Review Types

Packet Review Via Mail or Drop Off (no appointment


required)
The Family Self Help Program is providing you the option to either drop off or mail
your completed packet at either Self-Help location for paralegal review without
having to make an appointment. This service also includes the Self-Help Program
filing your approved packet with the Clerk of Court. Please carefully read the
instructions in your packet regarding packet completion and (click here) for
instructions to mail or drop off your packet for paralegal review.

First Time Visit (In-person appointment required)


Your packet is fully completed and is ready for Self-Help Paralegal review prior to
filing. The Self-Help service fee (see fee schedule) includes Paralegal review,
notarization of court documents, initial procedural information, follow-up procedural
information, and procedural information to obtain a hearing. To make your
appointment visit: https://www.jud11.flcourts.org/Family-Court-Self-Help-
Program/Appointments

Example: To make an appointment for a Post Judgment Modification packet, you will
select First-Time Visit Temporary Custody

The Family Court Self-Help Program


Self Help File No.: packet_number Receipt & Packet No.: packet_number
Printed on: 4/19/2023 11:38:12 AM
Packet Completion Assistance (In person
appointment required)
Need assistance completing your packet prior to filing? The Self-Help Program offers
packet completion assistance with a Self-Help Paralegal at a nominal fee (see fee
schedule) to help you complete your documents. To make your appointment visit:
https://www.jud11.flcourts.org/Family-Court-Self-Help-Program/Appointments
Example: To make an appointment for a Paternity Agreement packet, you will
select Packet Completion Assistance-Temporary Custody

➢ To cancel or reschedule your Self-Help Appointment visit:


https://www.jud11.flcourts.org/Family-Court-Self-Help-Program and click on FIND
APPOINTMENT

If you are not sure whether the Courts are open because of a possible Hurricane,
please call the 11th Judicial Circuit Hotline at 305-349-7777.

The Family Court Self-Help Program


Self Help File No.: packet_number Receipt & Packet No.: packet_number
Printed on: 4/19/2023 11:38:12 AM
SELF-HELP PACKET REVIEW VIA MAIL

The Family Self Help Program is providing you the option to either drop off or mail
your completed packet at either Self-Help location for paralegal review without
having to make an appointment. This service also includes the Self-Help Program
filing your approved packet with the Clerk of Court. Please carefully read the
instructions in your packet regarding packet completion and the instructions below
to mail or drop off your packet for paralegal review

Mail or drop off your completed packet at one of the following locations:
Self-Help Program Self-Help Program

Lawson E. Thomas Courthouse Center South Dade Government


Center
175 NW 1st Ave Suite 2441 10710 SW 211th St Room
1400
Miami, FL 33128 Miami, FL 33189

• Make sure all forms are completed in full, that they are legible, and have
each form that requires notarization to be notarized.
• You will only provide for review the original completed and notarized
packet accompanied with money orders for all the fees associated with the
type of packet you are submitting. See below for applicable fees for your
case. Please note that there are different agencies to whom the money
orders need to be made out to.
• Make sure to include a clear copy of the drivers license or valid ID along
with any of the required supporting documents. (Packet Instructions
include the required supporting documents needed)
• IMPORTANT: A Self-Help Paralegal will contact you either via phone or
email to confirm THAT YOUR PACKET HAS BEEN received and THAT

The Family Court Self-Help Program


Self Help File No.: packet_number Receipt & Packet No.: packet_number
Printed on: 4/19/2023 11:38:12 AM
PROCESSING IS UNDERWAY. (Please allow about two weeks FROM THE
MAILING DATE of your packet to receive notification from the Self-Help
Paralegal.)

SELF HELP SERVICE FEE


• $85 Dissolution of Marriage (Divorce),
• MAKE MONEY ORDER PAYABLE TO: MIAMI DADE COUNTY
*Processing Fee includes Copies, Postage and any additional documents
required for your remote hearing with the Judge or receive
Administrative Final Judgement without a hearing.

Select one of the following options below regarding filing type to determine
additional applicable fees:

Agreement
FEES DUE IF BOTH PARTIES ARE IN AGREEMENT
• Self-Help Service Fee (see Self-Help service fee section)
• Clerk of Court Filing Fee see fee schedule on our Self-Help website or
in packet instructions.
MAKE MONEY ORDER PAYABLE TO: CLERK OF COURT

The Family Court Self-Help Program


Self Help File No.: packet_number Receipt & Packet No.: packet_number
Printed on: 4/19/2023 11:38:12 AM
Important Information Regarding Your Self-Help Appointment

Need help completing your packet?


A Packet Completion Assistance is offered at the Self-Help Program to help you
complete your forms and notarize them. If you would like to participate in this service,
Make your appointment online: https://www.jud11.flcourts.org/Family-Court-Self-Help-
Program (Fee $125 agreement or $100 not in agreement)

Please have the following information below with your packet.

❖ Copy of Death Certificate (If the Death Certificate License is in a foreign


language, you must also submit a full English translation. The translator
must sign a certification that the English language translation is complete
and accurate, and that he or she is competent to translate from the foreign
language into English. The certification must include the translator’s
signature.)

❖ Copy of Petitioner and Respondents Driver’s (copies must be enlarged


and clear)

❖ Affidavit of Corroborating Witness Form (if applicable) Affidavit form


must be accompanied by a copy of your witness Florida Driver’s License
or Florida Identification

❖ 2 regular envelopes with 2 post office stamps

❖ Child(ren)/Adult Birth Certificate(s) (If the Birth Certificate(s) is/are in a


foreign language, you must also submit a full English translation. The
translator must sign a certification that the English language translation is
complete and accurate, and that he or she is competent to translate from
the foreign language into English. The certification must include the
translator’s signature.)
The Family Court Self-Help Program
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Form A-5
IN THE CIRCUIT COURT OF THE
ELEVENTH JUDICIAL CIRCUIT
IN AND FOR MIAMI-DADE COUNTY,
FLORIDA

FAMILY DIVISION
IN THE INTEREST OF

__________________________________,
Children CASE NO.:

__________________________________,
Petitioner,
and
__________________________________,
Respondent,

__________________________________,
Respondent.

PETITION FOR TEMPORARY CUSTODY BY EXTENDED FAMILY


Petitioner, {full legal name} , being sworn,
certifies that the following information is true:

1. This is an action for temporary custody pursuant to Chapter 751, Florida Statutes.

2. Petitioner requests temporary custody of the following minor children:


Name Date of Birth Current Address

3. Petitioner completed a Uniform Child Custody Jurisdiction and Enforcement Act


Affidavit, Florida Supreme Court Approved Family Law Form 12.902(d), which was
filed with this Petition. The affidavit includes the names and current addresses of the
persons with whom the children have lived during the past 5 years, the places where the
children have lived during the past 5 years, and information concerning any custody
proceeding in this or any other state with respect to the children. If the Affidavit is not
completely filled out, signed under oath, and filed with the Petition, the case may be
dismissed without hearing.

Page 1 of 5
Form A-5

The Family Court Self-Help Program


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4. Petitioner is an extended family member who is: {Choose one only}

Related to the minor children within the third degree by blood or marriage to a
parent;
OR
The stepparent of the minor children, is married to Respondent {full legal name}
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 children’s parents as an adverse
party;
OR
An individual who qualifies as fictive kin as defined in section 39.01, Florida
Statutes.

5. Petitioner’s relationship to the minor children is: ______________________.

6. The residence and post office address of the Petitioner is: ____________
________________________________________________________________ .

7. Petitioner is a proper person to be awarded temporary custody because: {Choose one


only}
Petitioner has the signed, notarized consent from both of the children’s legal
parents;
OR
Petitioner is caring full time for the children in the role of a substitute parent and
the children currently live with the Petitioner.

If Petitioner does not have the signed consents from both parents or is not caring for
the children full time as a substitute parent, Petitioner cannot obtain temporary
custody under Chapter 751, Florida Statutes. Petitioner should consult an attorney
about other options.

8. The legal parents of the children are:


a. ___________________________, whose current address is:_____________________
_______________________________________________________________________
_
b. ___________________________, whose current address is:_____________________
_______________________________________________________________________

Page 2 of 5
Form A-5

The Family Court Self-Help Program


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9. The Consents of Parent {full legal name} and/or Parent {full
legal name} is/are attached to the Petition.
OR
The Consent of Parent {full legal name} is not
attached because that parent is deceased. A certified copy of the proof of death is attached.
OR
Consent has NOT been obtained from the parents. The specific acts or omissions
of the parents which demonstrate that the parents have abused, abandoned, or neglected
the children as defined in Chapter 39, Florida Statutes are: (attach additional sheets if
necessary) _____

____________
____________

10. Petitioner requests temporary custody be granted for the following period of time:
________________________________________________________________.
The reasons that support this request are: _____

_____
_____
___________.

11. It is in the best interests of the children that the Petitioner have temporary custody of the
children for the following reasons:
______________________________________________________________________
______________________________________________________________________

12. ORDER OF PROTECTION


a. Petitioner IS NOT aware of any temporary or permanent order for
protection entered on behalf of or against either parent, the Petitioner, or the
children in Florida or any other jurisdiction.
OR
b. Petitioner IS aware of the following temporary or permanent orders for
protection entered on behalf of or against either parent, the Petitioner, or the
children in Florida or any other jurisdiction. The court entering the order and the
case number is:____________________________________________________

Page 3 of 5

The Family Court Self-Help Program


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Form A-5

13. TEMPORARY OR PERMANENT CHILD SUPPORT ORDERS


a. Petitioner IS NOT aware of any temporary or permanent orders for child
support for the minor children.
OR
b. Petitioner IS aware of the following temporary or permanent order for
child support for the minor children. The court entering the order and the case
number is: ______________________________________________________.

14. CHILD SUPPORT (Choose one only}


(You must have proof or waiver of service of process upon the parent(s) or a Waiver of
Service of Process and Consent for the court to consider an award for child support)
a. _____Petitioner requests the court to order the parents to pay child support.

b. Petitioner requests the court to redirect all or part of the parents’ existing
child support obligation(s) to the Petitioner.

c. _____ Petitioner requests the court to redirect all or part of the parents’ existing
child support obligation(s) to the Petitioner, and to award the Petitioner
retroactive child support.

15. Petitioner requests does not request that the court establish reasonable
visitation or a time-sharing schedule with the parents.

16. Petitioner requests does not request additional provisions which are related
to the children’s best interests, including, but not limited to, a reasonable plan for
transitioning custody. The additional provisions requested are:

Page 4 of 5

Form A-5

The Family Court Self-Help Program


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WHEREFORE, Petitioner requests that this Court grant the Petitioner temporary custody of the
children subject to this proceeding; award the Petitioner other relief as requested; and award any
other relief that 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: ___________________________
Street Address: ___________________________
City, State, Zip: ___________________________
Telephone No.: ___________________________
E-mail: ___________________________

STATE OF FLORIDA)
COUNTY OF MIAMI-DADE)

Sworn to or affirmed and signed before me on ________________ by


__________________________________.

___________________________________
NOTARY PUBLIC or DEPUTY CLERK

 Personally known
 Produced identification: ___________________________________________

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} ___________.

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The Family Court Self-Help Program


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INSTRUCTIONS FOR DILIGENT SEARCH
Because you do not know the other party’s address, you are required to search for his or her address before
filing your Petition by following Step 1, Step 2, Step 3 and Step 4 at the same time.
Step 1: Complete the three Diligent Search Letters and follow the instructions provided below.
Step 2: You will conduct a Search for your spouse using the Internet.
Step 3: You will conduct a Service Member (Military) search using the provided link.
Step 4: Complete the Affidavit of Search Inquiry on the Relatives of the respondent and follow
the instructions below. (Make sure to print legibly when completing the forms)

STEP 1: DILIGENT SEARCH LETTERS (FORM B)


1. Completely fill out all three (3) Diligent Search Letters (Form B) with your information,
the other party’s information and have them NOTARIZED.
2. Follow the highlighted instructions on each letter, some of them require a fee and/or self
addressed stamped envelope.
3. Make a copy of each completed letter for your records, mail them, and wait for the
responses. (You may send the letters via certified mail)
4. If you learn of an old address from your diligent search inquiry you will need to show the
court proof via return receipt from a certified letter with that address to confirm that it’s
not a current address for your spouse.
5. If you find a valid address for your spouse, immediately proceed to step 5.

STEP 2: INTERNET SEARCH


1. You will be required to search for the respondent using the internet.
2. You can use www.switchboard.com or any other people finder searches using the
internet.
3. The report results must include the respondent’s Full Name, Address History, Age,
Date of Birth, Phone Numbers and Possible Relatives. (Attach Report Results to
your packet)
4. If you learn of an old address from your diligent search inquiry you will need to show the
court proof via return receipt from a certified letter with that address to confirm that it’s
not a current address for your spouse.
5. If you find a valid address for your respondent, immediately proceed to step 5.

STEP 3: ARMED SERVICES MEMBER SEARCH USING PROVIDED LINK


Because you do not know the other party’s address, you will also be required to determine
whether the other party is now a member of the military service.
1. Using a computer with internet capability, go to the following link:

https://www.dmdc.osd.mil/appj/scra/welcome.xhtml
2. For the Military to do the online search, you must enter the other party’s last name, first
name AND either their social security number (twice) or their date of birth.
3. Once this information is entered, click on “Look Up”.
4. Print the document, which will include two pages to file with the clerk. If you find a
valid address for your spouse, immediately proceed to step 5.

The Family Court Self-Help Program


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STEP 4: AFFIDAVIT OF SEARCH INQUIRY ON RELATIVES OF THE RESPONDENT (Form B-2)
Because you do not know the other party’s address, you will also be required to inquire about the
respondent with his or her relatives, before filing your petition, by following these steps: (Make
sure to print legibly when completing the forms)
1. You must complete, in full, the Name of the Relative, Relation to Respondent, Relatives
Address, Relatives Phone Number and the result of the inquiry of your spouse’s address.
2. After you complete your relative inquiry, have the affidavit Notarized.
3. If you obtain an address from your Affidavit of Search Inquiry from the Relatives of the
respondent you may need to serve the spouse at that address or show the court proof,
such as the return receipt from a certified letter with that address, to confirm that it’s not a
current address for your spouse.
4. If you find a valid address for the respondent, immediately proceed to step 5.

Step 5: Make your appointment with Self-Help


If during any of the above searches you obtain a valid address, immediately make an
appointment with the Self Help Program to have the other party served via summons.
If after completing all of the above 4 steps you do NOT have a valid address, you should also
contact the Self Help Program to make an appointment for you next step in the process.
BRING all of your documentation to this appointment. For example, you should have
received your three (3) responses from the Diligent Search Letters (Form B), your completed
Affidavit of Search Inquiry on Relatives of the Spouse (Form B-2), the printed Armed
Services response to your inquiry and your completed internet search.

Make your appointment online https://www.jud11.flcourts.org/Family-Court-Self-


Help-Program to review and notarize your documents. Please read the Self-Help
Appointment Types sheet before scheduling your appointment.

The Family Court Self-Help Program


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Form B The Postal Service suggests the following format to be used in conjunction with
regulations at 39 CFR 265.6(d)(4)(ii) by persons empowered by law to serve legal process
when requesting change of address or boxholder information.
You will need to write to the Postmaster that is nearest to the last known address of the
person you are trying to locate. To find this Postmaster address, you need to call 1-800-
275-8777 and tell the person the last known address of the person you are trying to locate.
The person will give you the address of this nearest Postmaster to mail this form. The
request should be mailed to the Postmaster’s address that you write below.
Postmaster Address: ____________________________________________ Date: _____________

City ___________________, State_______, ZIP Code________________

REQUEST FOR CHANGE OF ADDRESS OR BOXHOLDER INFORMATION NEEDED FOR SERVICE OF


LEGAL PROCESS
Please furnish the new address or the name and street address (if a boxholder) for the following:
Name (other party) you are trying to find_________________________________________
Last Known Address of this person________________________________________________
________________________________________________
Note: Only one request may be made per completed form. The name and last known address are required
for change of address information. The name, if known and Post Office box address are required for
boxholder information.
The following information is provided in accordance with 39 CFR 265.6(d)(4)(ii). There is no fee charged
for change of address or boxholder information.
1. Capacity of requester (process server, attorney, party representing self): Party Representing Self
2. Statute or regulation that empowers me to serve process (not required for attorney’s or a party acting pro
se—except a corporation acting pro se must cite statute: N/A
3. The names of all known parties to the litigation:_____________________________________________
4. The court in which the case has been or will be heard: Eleventh Judicial Circuit, Family Division
5. The docket or other identifying number (a or b must be completed)
___ a. Docket or other identifying number:_____________________________
X b. Docket or other identifying number has not been issued.
6. The capacity in which this individual is to be served (petitioner, respondent or witness)


Respondent Petitioner □
WARNING: THE SUBMISSION OF FALSE INFORMATION TO OBTAIN AND USE CHANGE OF
ADDRESS INFORMATION OR BOXHOLDER INFORMATION FOR ANY PURPOSE OTHER THAN THE
SERVICE OF LEGAL PROCESS IN CONNECTION WITH ACTUAL OR PROSPECTIVE LITIGATION
COULD RESULT IN CRIMINAL PENALTIES INCLUDING A FINE OF UP TO $10,000 OR
IMPRISONMENT OF NOT MORE THAN 5 YEARS, OR BOTH (TITLE 18 U.S.C. SECTION 1001).
I certify that the above information is true and that the address information is needed and will be used solely
for service of legal process in conjunction with actual or prospective litigation.

__________________________________ _______________________________________
Signature Address
_________________________________ _________________________________________
Printed Name City, State, ZIP Code

------------------------------------------------------------------------------------------------------------------------------------------
FOR POST OFFICE USE ONLY
_____ No change of address on file New Address or Boxholder Name and Street Address
_____ Moved and left no forwarding address __________________________________________
_____ No such address __________________________________________

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Form B

Division of Motorist Services Date: ___________________, 20_____


2900 Apalachee Parkway
Room # B231, Mail Stop 57
Neil Kirkman Building
Tallahassee, Florida 32399
To Whom It May Concern:
I am filing a legal action in the 11th Judicial Circuit in Miami-Dade County and I do not
know the whereabouts of the respondent. I need to conduct a search to see if the respondent is
living in the State of Florida. Therefore, I need your Department to advise me as to whether there
are any motor vehicles in Florida titled or registered to the respondent’s address and if so, the
address on the title or registration.
This request is made under Driver Privacy Protection Act Exemption number four (4)
For use in connection with any civil, criminal, administrative, or arbitral proceeding in any Federal,
State, or local court or agency or before any self-regulatory body, including the service of process,
investigation in anticipation of litigation, and the execution or enforcement of judgments and orders, or
pursuant to an order of a Federal, State, or local court.

Listed below is the information on the Respondent:


Full Name: ____________________________________________________
Last Known Address: ______________________________________________
Date of Birth: ____________________________________________________
Driver License/ID #: _______________________________________________
Social Security #: ______________________________________________
I am enclosing a Check / Money Order for $.50 made out to “Florida Division of
Motor Vehicles” to pay for a non-certified computer printout. Thank you for your
cooperation.
Dated: ________________ Signature of Party: __________________________
Printed Name:______________________________
Street Address:______________________________
City, State, Zip:______________________________
Telephone No.:______________________________
Email Address:______________________________
STATE OF FLORIDA)
COUNTY OF MIAMI-DADE)
Sworn to or affirmed and signed before me on ________________ by
______________________________________.
___________________________________
NOTARY PUBLIC or DEPUTY CLERK
_____ Personally known
_____ Produced identification: ___________________________________________

The Family Court Self-Help Program


Self Help File No.: packet_number Receipt & Packet No.: packet_number
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Form B

Department of Corrections Date: ___________________, 20_____


501 South Calhoun Street
Tallahassee, Florida 32399-2500

To Whom It May Concern:

I am filing a legal action in the 11th Judicial Circuit in Miami-Dade County and I
do not know the whereabouts of the respondent. I need to conduct a search to see if the
respondent is living in the State of Florida. Therefore, I need your Department to advise
me as to whether the respondent is incarcerated in Florida and if so, the address to which
mail be sent. Listed below is the information for the respondent:

Full Name: ________________________________________________


Social Security Number: ________________________________________
Date of Birth: ________________________________________________

Enclosed please find a self-addressed, stamped envelope. Thank you for your cooperation.

Sincerely:

Signature of Party: __________________________


Printed Name: ___________________________
Street Address: ___________________________
City, State, Zip: ___________________________

STATE OF FLORIDA)
COUNTY OF MIAMI-DADE)

Sworn to or affirmed and signed before me on ________________ by


______________________________________.

___________________________________
NOTARY PUBLIC or DEPUTY CLERK

_____ Personally known


_____ Produced identification: ___________________________________________

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Form
IN THE CIRCUIT COURT OF THE
ELEVENTH JUDICIAL CIRCUIT
IN AND FOR MIAMI-DADE COUNTY,
FLORIDA

FAMILY DIVISION
IN RE:

_____________________________,
Petitioner, CASE NO.: FC
and

_____________________________,
Respondent.
AFFIDAVIT OF SEARCH INQUIRY ON
RELATIVES OF THE PARENT

Please list names, addresses and phone number of relatives and contacts with those
relatives, and inquiry as to Respondent’s last known address. You are to follow up any
leads of any address where the Respondent may have moved. The respondent’s relatives
include, but are not limited to: parents, brothers, sisters, aunts, uncles, cousins, nieces,
grandparents, great-grandparents, stepparents, stepchildren.

Name of relative: ________________________________________________________


Relation to Respondent: ___________________________________________________
Relatives Address: _______________________________________________________
Relatives phone number: __________________________________________________
Result of inquiry: ________________________________________________________

Name of relative: ________________________________________________________


Relation to Respondent: ___________________________________________________
Relatives Address: _______________________________________________________
Relatives phone number: __________________________________________________
Result of inquiry: ________________________________________________________

Name of relative: ________________________________________________________


Relation to Respondent: ___________________________________________________
Relatives Address: _______________________________________________________
Relatives phone number: __________________________________________________
Result of inquiry: ________________________________________________________
Affidavit of Search Inquiry of Relatives of Spouse page 1 of 2

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Form CASE # _________________________

Name of relative: ________________________________________________________


Relation to Respondent: ___________________________________________________
Relatives Address: _______________________________________________________
Relatives phone number: __________________________________________________
Result of inquiry: ________________________________________________________

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: ___________________________
Street Address: ___________________________
City, State, Zip: ___________________________
Telephone No.: ___________________________

STATE OF FLORIDA)
COUNTY OF MIAMI-DADE)

Sworn to or affirmed and signed before me on ________________ by


__________________________.

___________________________________
NOTARY PUBLIC or DEPUTY CLERK
_____ Personally known
_____ Produced identification: ___________________________________________

Affidavit of Search Inquiry of Relatives of Spouse page 2 of 2

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Form C
IN THE CIRCUIT COURT OF THE
ELEVENTH JUDICIAL CIRCUIT
IN AND FOR MIAMI-DADE COUNTY,
FLORIDA

FAMILY DIVISION

IN THE INTEREST OF

__________________________________,
Children CASE NO.:

__________________________________,
Petitioner,
and
__________________________________,
Respondent,

__________________________________,
Respondent.
AFFIDAVIT OF DILIGENT
SEARCH AND INQUIRY

I, {full legal name} ___________________________________, being sworn, certify that the


following information is true:

1. I have made diligent search and inquiry to discover the name and current residence of
Respondent: {Specify details of search} Refer to checklist below and identify all actions taken
(any additional information included such as the date the action was taken and the person with
whom you spoke is helpful) (attach additional sheet if necessary):

[√ all that apply]


_____ United States Post Office inquiry through Freedom of Information Act for current address or any
relocations.
_____ Last known employment of Respondent, including name and address of employer. You should
also ask for any address to which W-2 Forms were mailed, and, if a pension or profit-sharing plan
exists, then for any addresses to which any pension or plan payment is and/or has been mailed.
_____ Unions from which Respondent may have worked or that governed particular trade or craft.
_____ Regulatory agencies, including professional or occupational licensing.
_____ Names and addresses of relatives and contacts with those relatives, and inquiry as to Respondent’s
last known address. You are to follow up any leads of any addresses where Respondent may
have moved. Relatives include, but are not limited to: parents, brothers, sisters, aunts, uncles,
cousins, nieces, nephews, grandparents, great-grandparents, former in-laws, stepparents,
stepchildren.
_____ Information about the Respondent’s possible death and, if dead, the date and location of the death.
_____ Telephone listings in the last known locations of Respondent’s residence.

Affidavit of Diligent Search 1 of 3

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Form C

_____ Internet at http://www.switchboard.com or other Internet people finder or the library checked for
me.
_____ Law enforcement arrest and/or criminal records in the last known residential area for Respondent.
_____ Highway Patrol records in the state of Respondent’s last known address.
_____ Department of Motor Vehicle records in the state of Respondent’s last known address.
_____ Title IV-D (child support enforcement) agency records in the state of Respondent’s last known
address.
_____ Hospital in the last known area of Respondent’s residence.
_____ Utility companies, which include water, sewer, cable TV, and electric, in the last known area of
Respondent’s residence.
_____ Armed Forces of the U.S. printed response as to whether or not there is any information about
Respondent.
_____ Tax Assessor’s and Tax Collector’s Office in the area where Respondent last resided.
_____ Other {explain}: _________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

2. The age of Respondent is [√ only one box]  known {enter age}__________ or  unknown.

3. Respondent’s current residence


[√ only one box]
 a. Respondent’s current residence is unknown to me.
 b. Respondent’s current residence is in some state or country other than Florida, and
Respondent’s last known address is: _________________________________________________
______________________________________________________________________________.
 c. The Respondent, having residence in Florida, has been absent from Florida for more than 60
days prior to the date of the affidavit, or conceals him(her)self so that process cannot be served
personally upon him or her, and I believe there is no person in the state upon whom service of
process would bind this absent or concealed Respondent.

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Form C

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: ___________________________
Street Address: ___________________________
City, State, Zip: ___________________________
Telephone No.: ___________________________
E-mail: ___________________________

STATE OF FLORIDA)
COUNTY OF MIAMI-DADE)

Sworn to or affirmed and signed before me on ________________ by


__________________________________.

___________________________________
NOTARY PUBLIC or DEPUTY CLERK

 Personally known
 Produced identification: ___________________________________________

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Form D
IN THE CIRCUIT COURT OF THE
ELEVENTH JUDICIAL CIRCUIT
IN AND FOR MIAMI-DADE COUNTY,
FLORIDA
FAMILY DIVISION
IN THE INTEREST OF

__________________________________,
Children CASE NO.:

__________________________________,
Petitioner,
and
__________________________________,
Respondent,

__________________________________,
Respondent.

NOTICE OF PUBLICATION
YOU, Respondent ____________________________________ whose last
known address is _________________________________________________________
are hereby notified regarding the following child(ren) ____________________________,
_______________________________, _____________________________________, to
file your Answer to the Petition for Temporary Custody with the Clerk of the Court and
mail a copy to the Petitioner at ______________________________________________
_____________________________________________________________ on or before
the __________ Day of ________________________, 20 _______ or this Petition for
Temporary Custody filed against you will be taken as confessed.
Dated this _______ Day of _______________________________, 20 _______.

CLERK OF THE CIRCUIT COURT


By: ________________________________
Deputy Clerk
(Circuit Court Seal)

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RULES FOR COMPLETING A MOTION
To correctly file a motion to request something from the Court, you must do
the following:
1. Write in English and in blue or black ink.
2. Write in complete sentences and only on the front of the page.
3. Write only the facts supporting your request.
4. Write what kind of case you have filed.
a. Example: Divorce, Establishing Paternity
5. Use first and last names when referring to a person, do not use “he” or “she”.
6. When talking about a child, write the child’s date of birth next to the child’s
name.
7. Attach a copy of any document that you talk about in your motion.
8. Write the address of the other person in the case at the end of the motion in the
space provided.
a. You MUST mail a copy to the other person in the case.
9. Even if the motion is filed as an Emergency Motion, it is up to the Judge to
determine if the motion is an emergency and when the motion will be heard. The
Judge may require notice to the other party (Due Process) before holding the
hearing on an Emergency Motion.

REGLAS PARA COMPLETAR UNA MOCION


Para presentar una moción correctament pidiendo algo en la Corte, Debe
hacer lo siguiente:
1. Escriba en Inglés y en tinta negra o azúl.
2. Escriba frases completas y solamente en la parte delantera de la página.
3. Escriba solamente acerca de los hechos de los que Ud. está pidiendo.
4. Escriba que clase de caso tiene en la Corte.
a. Por ejemplo: Divorcio, Para Establecer Paternidad
5. Use los nombres completos cuando se refiera a la otra persona. No use “el” o
“ella”.
6. Cuando esté refiriendose acerca de un/a menor de edad, escriba la fecha de
nacimiento del menor junto al nombre.
7. Adjunte con su moción cualquier documento del cuál se está refiriendo.
8. Escriba la dirección postal completa de la otra persona en su caso, al final de su
moción en el espacio indicado.
a. Debe mandar una copia a la otra persona en su caso por correo.
9. Aún si su moción está siendo presentada como una Emergency Motion (Mocion
de Emergencia), depende completamente del Sr./Sra. Juez el determinar si la
moción és o no es una emergencia y cuando seria celebrada la Audiencia. El/la
Juez puede exigir que la otra parte sea notificacada (Due Process) Proceso Debido
antes de celebrar la Audiencia.

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Form F
IN THE CIRCUIT COURT OF THE
ELEVENTH JUDICIAL CIRCUIT
IN AND FOR MIAMI-DADE COUNTY,
FLORIDA

FAMILY DIVISION
IN THE INTEREST OF

__________________________________,
Children CASE NO.:

__________________________________,
Petitioner,
and
__________________________________,
Respondent,

__________________________________,
Respondent.

MOTION__________________________

___________________________________

( ) Petitioner ( ) Respondent, {name} _______________________________, files


this Motion _______________________________________________________________
and in support alleges the following:

1. I am filing this motion because:________________________________________


______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_____________________________________________________________________
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Form F

2. I request the following from the Court:________________________________


______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_____________________________________________________________________

3.

4.

5.

6.

Blank Motion page 2

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Form F

7.

I certify that a copy of the foregoing was mailed to the person listed below on
{date} ________________________:

Other party or his/her attorney:


Name: __________________________
Street Address: __________________________
City, State, Zip: __________________________
Telephone No.: __________________________

Dated: ________________ Signature of Party: __________________________


Printed Name: ___________________________
Street Address: ___________________________
City, State, Zip: ___________________________
Telephone No.: ___________________________
E-mail: ___________________________

STATE OF FLORIDA)
COUNTY OF MIAMI-DADE)

Sworn to or affirmed and signed before me on ________________ by


__________________________.

___________________________________
NOTARY PUBLIC or DEPUTY CLERK

_____ Personally known


_____ Produced identification: ___________________________________________

Blank Motion page 3

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IN THE CIRCUIT COURT OF THE
ELEVENTH JUDICIAL CIRCUIT
IN AND FOR MIAMI-DADE COUNTY,
FLORIDA

:FAMILY DIVISION
IN THE INTEREST OF

__________________________________,
Children CASE NO.:

__________________________________,
Petitioner,
and
__________________________________,
Respondent,

__________________________________,
Respondent. REQUEST FOR HEARING

1. Motion for which hearing is requested:________________________________________


______________________________________________________________________
2. Amount of time requested: _____________
3. Check one of the below:
_____ I have conferred with the opposing party in a good faith effort to resolve the matters
without a hearing and to determine the amount of time requested for the hearing;
OR
_____ I have been unable to confer with opposing party because:
________________________________________________________________
4. FOR EMERGENCY MOTIONS ONLY: I hereby certify that this matter is an emergency in my
judgment, the grounds of which are reflected in the motion itself.
I certify that a copy of the foregoing was mailed to the person listed below on {date}
________________________:
Other party or his/her attorney:
Name: _______________________
Street Address: _______________________
City, State, Zip: _______________________
Telephone No.: _______________________
Dated: ________________ Signature of Party: _______________________
Printed Name: ________________________
Street Address: ________________________
City, State, Zip: ________________________
Telephone No.: ________________________
E-mail: ______________________
Request for Hearing

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Form G

IN THE CIRCUIT COURT OF THE ELEVENTH JUDICIAL CIRCUIT,


IN AND FOR MIAMI-DADE COUNTY, FLORIDA

IN THE INTEREST OF FAMILY DIVISION

__________________________________,
Children CASE NO.:

__________________________________,
Petitioner,
and
__________________________________,
Respondent,

__________________________________,
Respondent.

SUMMONS: PERSONAL SERVICE ON AN INDIVIDUAL


ORDEN DE COMPARECENCIA: SERVICIO PERSONAL EN UN INDIVIDUO
CITATION: L’ASSIGNATION PERSONAL SUR UN INDIVIDUEL

TO: (other party’s full legal name)


Name: ______________________________
Street Address: ______________________________
City, State, Zip: ______________________________

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 petition with the Clerk of the Court,
located at 175 N.W. 1st Avenue, 12th Floor, Miami, Florida 33128. A phone call will not
protect you. Your written response, including the case number 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).

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Form G

If you choose to file a written response yourself, at the same time you file your written
response to the Court, you must also mail or take a copy of your written response to the party
serving this summons at:
Party Name: _________________________
Street Address: _________________________
City, State, Zip: _________________________

Copies of all court documents in this case, including orders, are available at the Clerk of
the Court’s office. You may review these documents upon request. You must keep the Clerk of
the Court’s office notified of your current address. Future papers in this lawsuit will be mailed to
the address on record at the clerk’s office.

WARNING: Rule 12.285, Florida Family 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 20 dias, contados a partir del recibo de esta
notificacion, para contestar la demanda adjunta, pro escrito, y presentarla ante este tribunal.
Localizado en 175 N.W. 1st Avenue, 12th Floor, Miami, Florida 33128. 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.

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Form G

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: _____________________________
Direccion: _____________________________
Ciudad, Estado, Zip: ________________________
Copias de todos los documentos judiciales de este caso, incluyendo las ordenes, estan
disponibles en la oficina del Clerk of the Court. Estos documentos pueden ser revisados a su
solicitud.

Usted debe de manener informada a la oficina del Clerk of the Court de su direccion
actual. Los papelos que se presenten en el futuro en esta demanda judicial seran envados por
correo a la direccion que este registrada en la oficina del Clerk.

ADVERTENCIA: Regla 12.285 del Florida Family Law Rules of Procedure, requiere
cierta revelacion automatica de documentos e informacion. El incumplimient, puede resultar en
sanciones, includyendo la desestimacion o anulacion de los alegatos.

IMPORTANT

Des poursuites judiciaries ont ete enterprises 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: Clerk of the Court, 175 N.W. 1st
Avenue, 12th Floor, Miami, Florida 33128. 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
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 de 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).

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Form G

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: _____________________________
Adresse: _____________________________
_____________________________
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. 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 petition in this lawsuit on the above-named person.

DATED: _________________

CLERK OF THE CIRUIT COURT

By: _______________________________
Deputy Clerk

Dade County Courthouse Coral Gables District Court Joseph Caleb Center
73 West Flagler Street, Room 138 3100 Ponce de Leon Blvd., Ste. 100 5400 N.W. 22 Avenue, Ste. 205
Miami, Florida 33130 Coral Gables, Florida 33134 Miami, Florida 33142

Hialeah District Court Cutler Ridge District Court Miami Beach District Court
11 East 6th Street 10710 S.W. 211 Street, Room 224 1130 Washington Ave., Ste. 224
Hialeah, Florida 33010 Miami, Florida 33189 Miami Beach, Florida 33139

North Dade Justice Center Lawson E. Thomas Courthouse Sweetwater Branch


15555 Biscayne Blvd., Ste. 100 175 N.W. 1st Avenue, 12th Floor 500 S.W. 109 Avenue, 3rd Fl.
Miami, Florida 33160 Miami, Florida 33128 Sweetwater, Florida 33174

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Form H FAMILY COURT COVER SHEET

Case Style: IN RE: CIRCUIT COURT OF THE ELEVENTH


JUDICIAL CIRCUIT, IN AND FOR
______________________________ MIAMI DADE COUNTY, FLORIDA
Petitioner,
and
Case No.: _______________________
______________________________
Respondent. Judge: __________________________
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.
■ Initial Action/Petition
□ Reopening Case
□ Modification/Supplemental Petition
□ Motion for Civil Contempt/Enforcement
□Other __________________________________
Type of Case. If the case fits more than one type of case, select the most definitive. If the
most definitive label is a subcategory (indented under a broader category label), place a check in
the category and subcategory boxes.
□ Simplified Dissolution ■ Other Family Court Temp Custody
□ Dissolution of Marriage □ Name Change
□ Support IV-D (Dept of Revenue, CSE) □ Paternity/Disestablish Paternity
□ Support Non-IV-D (NOT Dept of Rev) □ Petition for Dependency
□ UIFSA IV-D (Dept of Revenue, CSE) □ CINS/FINS
□ UIFSA Non-IV-D (NOT Dept of Revenue, CSE)_____________________________
Rule of Judicial Administration 2.545(d) requires that a NOTICE OF RELATED CASES
form be filed with the initial pleading. Are there related cases?
□ No, to the best of my knowledge, no related cases exist.
□ Yes, all related cases are listed on RELATED CASES form.
PARTY SIGNATURE
I CERTIFY that the information I have provided in this cover sheet is accurate to the best
of my knowledge and belief.

___________________________ ____________________________ __________________


Party Signature (Type or print your name) Date

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Form J
IN THE CIRCUIT COURT OF THE
ELEVENTH JUDICIAL CIRCUIT
IN AND FOR MIAMI-DADE COUNTY,
FLORIDA

FAMILY DIVISION

, CASE NO.:
Petitioner,
and

, UNIFORM CHILD CUSTODY


Respondent. 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 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:
Date Address (including city and Name and present address of Relationship
(From/To) state) where child lived person child lived with to child

______ / Present*

______ / _______

______ / ______

______ /
______

______ / ______

* If you are the Petitioner in an injunction for protection against domestic violence case and you have filed Petitioner’s
Request for Confidential Filing of Address. Florida Family Law Form 12.980(i), you should write “confidential” in
any space on this form that would require you to enter the address where you are currently living

Uniform Child Custody Jurisdiction and Enforcement Affidavit (UCCJEA) Page 1

The Family Court Self-Help Program


Self Help File No.: packet_number Receipt & Packet No.: packet_number
Printed on: 4/19/2023 11:38:12 AM
Form J
THE FOLLOWING INFORMATION IS TRUE ABOUT CHILD #2:

Child’s Full Legal Name: _________________________________________________


Place of Birth: Date of Birth: Sex: _____
Child’s Residence for the past 5 years:
Date Address (including city and Name and present address of Relationship
(From/To) state) where child lived person child lived with to child

______ / Present*

______ / _______

______ / ______

______ /
______

______ / ______

THE FOLLOWING INFORMATION IS TRUE ABOUT CHILD # 3:

Child’s Full Legal Name: _________________________________________________


Place of Birth: Date of Birth: Sex: _____
Child’s Residence for the past 5 years:
Date Address (including city and Name and present address of Relationship
(From/To) state) where child lived person child lived with to child

______ / Present*

______ / _______

______ / ______

______ /
______

______ / ______

Uniform Child Custody Jurisdiction and Enforcement Affidavit (UCCJEA) Page 2

The Family Court Self-Help Program


Self Help File No.: packet_number Receipt & Packet No.: packet_number
Printed on: 4/19/2023 11:38:12 AM
Form J
2. Participation in custody proceeding(s):[ one]:
______ I HAVE NOT participated as a party, witness, or in any capacity in any other
litigation or custody proceeding in this or any other state concerning custody of a child
subject to this proceeding.
______ I HAVE participated as a party, witness, or in any capacity in any other litigation
or custody proceeding in this or another state, concerning custody of 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 proceeding(s): [ one only]

______ I HAVE NO INFORMATION of any custody proceeding pending in a court of


this or any other state concerning a child subject to this proceeding.
______ I HAVE THE FOLLOWING INFORMATION concerning a custody 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: _________________________________________________
b Type of proceeding: __________________________________________________
c. Court and State:____________________________________________________
d. Date of court order or judgment (if any): ________________________________
4. Person not a party to this proceeding:[ one only]
______ I DO NOT KNOW OF ANY PERSON not a party to this proceeding who has
physical custody or claims to have custody or visitation rights with respect to any child
subject to this proceeding.
______ I KNOW THAT THE FOLLOWING NAMED PERSON(S) not a party to this
proceedings has (have) physical custody or claim (s) to have custody or visitation rights
with respect to any child subject to this proceedings:
a. Name and address of person: ___________________________________________
__________________________________________________________________
( ) has physical custody ( ) claims custody rights ( ) claims visitation rights.
Name of each child: ___________________________________________________

b. Name and address of person: __________________________________________


_________________________________________________________________
( ) has physical custody ( ) claims custody rights ( ) claims visitation rights.
Name of each child:___________________________________________________

c. Name and address of person: ___________________________________________


__________________________________________________________________
( ) has physical custody ( ) claims custody rights ( ) claims visitation rights.
Name of each child:__________________________________________________

Uniform Child Custody Jurisdiction and Enforcement Affidavit (UCCJEA) Page 3

The Family Court Self-Help Program


Self Help File No.: packet_number Receipt & Packet No.: packet_number
Printed on: 4/19/2023 11:38:12 AM
Form J

5. Knowledge of prior child support proceeding(s): [ one only]


______ The child(ren) described in this affidavit are NOT subject to existing child
support order(s) in this or any state or territory.
______The child(ren) described in this affidavit are subject to the following existing
child support order(s):
a. Name of each child: _______________________________________________
b. Type of proceeding: _______________________________________________
c. Court and Address: ________________________________________________
d. Date of court order or judgment (if any): _______________________________
e. Amount of child support paid and by whom: ____________________________

1. I acknowledge that I have a continuing duty to advise this Court of any custody,
visitation, child support, or guardianship proceeding (including dissolution of marriage,
separate maintenance, child neglect, or dependency) concerning the child(ren) in this
state of any other state about which information is obtained during this proceeding.

I certify that a copy of this document was [ one only] ( ) mailed ( ) faxed and 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: ______________________________
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 included
fines and/or imprisonment.
Dated: ___________________ Signature of Party:_______________________________
Printed Name:__________________________________
Address:_______________________________________
City, State, Zip:_________________________________
Phone Number:_________________________________
STATE OF FLORIDA
COUNTY OF MIAMI-DADE
Sworn to or affirmed and signed before me on by .

_________________________________________
NOTARY PUBLIC-STATE OF FLORIDA
[Print, type or stamp commissioned name of notary.]
Personally known
Produced identification
Type of identification produced _________________________

Uniform Child Custody Jurisdiction and Enforcement Affidavit (UCCJEA) Page 4

The Family Court Self-Help Program


Self Help File No.: packet_number Receipt & Packet No.: packet_number
Printed on: 4/19/2023 11:38:12 AM
Form L-4
IN THE CIRCUIT COURT OF THE
ELEVENTH JUDICIAL CIRCUIT
IN AND FOR MIAMI-DADE COUNTY,
FLORIDA
FAMILY DIVISION
IN THE INTEREST OF

_________________________________
Children

__________________________________,
Petitioner,
and
__________________________________,
Respondent,

__________________________________,
Respondent.

WAIVER OF SERVICE OF PROCESS AND CONSENT FOR


TEMPORARY CUSTODY BY EXTENDED FAMILY

I, {full legal name} , the legal parent of


{children’s names} , having received a copy
of the Petition for Temporary Custody by Extended Family filed herein and waived service of
process, freely and voluntarily consent to the Petition filed by: {Petitioner’s full legal name}

.
I realize that by signing this document, I am consenting to the Petitioner having temporary legal
custody of the minor children and that such temporary custody is in the best interest of the children.
Upon entry of an Order, the Petitioner shall be able to:
1. Consent to all necessary and reasonable medical and dental care for the children, including
nonemergency surgery and psychiatric care;
2. Secure copies of the children’s records, held by third parties, that are necessary for the care
of the child(ren), including, but not limited to:
a. Medical, dental, and psychiatric records;
b. Birth Certificates and other records; and
c. Educational records.
3. Enroll the children in school and grant or withhold consent for the children to be tested or
placed in special school programs, including exceptional education; and
4. Do all other things necessary for the care of the children.
Consent for Temporary Custody and Waiver 1 of 2

The Family Court Self-Help Program


Self Help File No.: packet_number Receipt & Packet No.: packet_number
Printed on: 4/19/2023 11:38:12 AM
Form L-4

I realize that the custody of my children by the Petitioner is temporary and that I may, at any time,
petition the court to return legal custody to me. I understand and acknowledge that I may have to
comply with a reasonable transition plan prior to the court returning legal custody to me.

Dated: ________________ _______________________________________


Signature of Parent
Printed Name: ________________________
Street Address: ________________________
City, State, Zip: ________________________
Telephone No.: ________________________
E-mail: ________________________

STATE OF FLORIDA)
COUNTY OF MIAMI-DADE)

Sworn to or affirmed and signed before me on ________________ by


__________________________.

___________________________________
NOTARY PUBLIC or DEPUTY CLERK

_____ Personally known


_____ Produced identification: ___________________________________________

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}
________________________

Consent for Temporary Custody and Waiver 2

The Family Court Self-Help Program


Self Help File No.: packet_number Receipt & Packet No.: packet_number
Printed on: 4/19/2023 11:38:12 AM
Form L-4
IN THE CIRCUIT COURT OF THE
ELEVENTH JUDICIAL CIRCUIT
IN AND FOR MIAMI-DADE COUNTY,
FLORIDA
FAMILY DIVISION
IN THE INTEREST OF

_________________________________
Children

__________________________________,
Petitioner,
and
__________________________________,
Respondent,

__________________________________,
Respondent.

WAIVER OF SERVICE OF PROCESS AND CONSENT FOR


TEMPORARY CUSTODY BY EXTENDED FAMILY

I, {full legal name} , the legal parent of


{children’s names} , having received a copy
of the Petition for Temporary Custody by Extended Family filed herein and waived service of
process, freely and voluntarily consent to the Petition filed by: {Petitioner’s full legal name}

.
I realize that by signing this document, I am consenting to the Petitioner having temporary legal
custody of the minor children and that such temporary custody is in the best interest of the children.
Upon entry of an Order, the Petitioner shall be able to:
5. Consent to all necessary and reasonable medical and dental care for the children,
including nonemergency surgery and psychiatric care;
6. Secure copies of the children’s records, held by third parties, that are necessary
for the care of the child(ren), including, but not limited to:
a. Medical, dental, and psychiatric records;
b. Birth Certificates and other records; and
c. Educational records.
7. Enroll the children in school and grant or withhold consent for the children to be
tested or placed in special school programs, including exceptional education; and
8. Do all other things necessary for the care of the children.
Consent for Temporary Custody and Waiver 1 of 2

The Family Court Self-Help Program


Self Help File No.: packet_number Receipt & Packet No.: packet_number
Printed on: 4/19/2023 11:38:12 AM
Form L-4

I realize that the custody of my children by the Petitioner is temporary and that I may, at any time,
petition the court to return legal custody to me. I understand and acknowledge that I may have to
comply with a reasonable transition plan prior to the court returning legal custody to me.

Dated: ________________ _______________________________________


Signature of Parent
Printed Name: ________________________
Street Address: ________________________
City, State, Zip: ________________________
Telephone No.: ________________________
E-mail: ________________________

STATE OF FLORIDA)
COUNTY OF MIAMI-DADE)

Sworn to or affirmed and signed before me on ________________ by


__________________________.

___________________________________
NOTARY PUBLIC or DEPUTY CLERK

_____ Personally known


_____ Produced identification: ___________________________________________

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} ________________________

Consent for Temporary Custody and Waiver 2

The Family Court Self-Help Program


Self Help File No.: packet_number Receipt & Packet No.: packet_number
Printed on: 4/19/2023 11:38:12 AM
IN THE CIRCUIT COURT OF THE ELEVENTH JUDICIAL CIRCUIT
IN AND FOR MIAMI-DADE COUNTY,
FLORIDA

FAMILY DIVISION
IN THE INTEREST OF

__________________________________,
Children CASE NO.:

__________________________________,
Petitioner,
and
__________________________________,
Respondent,

__________________________________,
Respondent,

VI. INDEX OF FORMS


□ Form A-5 Petition for Temporary Custody
□ Form B 3 Letters of Diligent Search
□ Form Affidavit Search & Inquiry on Relatives of Spouse
□ Form C Affidavit of Diligent Search and Inquiry
□ Form D Notice of Publication
□ Form F Blank Motion and Request for Hearing
□ Form G Summons for Father
□ Form G Summons for Mother
□ Form Certificate of Death for Father
□ Form Certificate of Death for Mother
□ Form H Civil Cover Sheet
□ Form L-4 Consent for Temporary Custody & Waiver for Father
□ Form L-4 Consent for Temporary Custody & Waiver for Mother
□ Form II Notice of Final Uncontested Hearing
□ Form WW Final Judgment Awarding Temporary Custody
□ Form Notice of Related Cases
□ Form Acknowledgment of Receipt
□ Form Designation of Current Mailing and E-mail Address (Petitioner)
□ Form Designation of Current Mailing and E-mail Address (Respondent)

Index of Forms (Temporary Custody)

The Family Court Self-Help Program


Self Help File No.: packet_number Receipt & Packet No.: packet_number
Printed on: 4/19/2023 11:38:12 AM
IN THE CIRCUIT COURT OF THE
ELEVENTH JUDICIAL CIRCUIT
IN AND FOR MIAMI-DADE COUNTY,
FLORIDA
FAMILY DIVISION

IN RE: Temporary Custody


CASE NO.:
_____________________________,
Petitioner,
and NOTICE OF RELATED CASES
_____________________________,
Respondent.
_______________________________/
In compliance with Florida Rule of Judicial Administration 2.545(d), the petitioner in a
family case must file with the court a Notice of Related Cases, if related cases are known or
reasonably ascertainable. A related case may be an open or closed civil, criminal, family,
guardianship, domestic violence, juvenile delinquency, juvenile dependency, or domestic
relations case. A case is “related” to this family case if:
(A) it involves any of the same parties, children, or issues and it is pending at the time the
party files a family case; or
(B) it affects the court’s jurisdiction to proceed; or
(C) an order in the related case may conflict with an order on the same issues in the new
case; or
(D) an order in the new case may conflict with an order in the earlier litigation.
Have you ever had contact with the Department of Children and Families regarding children
included in this Petition?  Yes  No
(check one only)
 There are no related cases.
 The following are the related cases (add additional pages if necessary)
Related Case No. 1
Case Type:  Criminal  Juvenile Dependency/Delinquency  Child Support Enforcement
 Domestic/Sexual/Dating/Repeat Violence or Stalking Injunctions  Unified Family Court
 Dissolution of Marriage  Paternity  Adoption  Other ___________________
Case Number: _______________________________________________
County/State/Court: __________________________________________
Pending  or Closed? If closed, date closed________________
Title of last Court Order/Judgment: ______________________________
Date of Court Order/Judgment: _________________________________
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:____________________________________
________________________________________________________________________

Notice of Related Cases page 1

The Family Court Self-Help Program


Self Help File No.: packet_number Receipt & Packet No.: packet_number
Printed on: 4/19/2023 11:38:12 AM
Related Case No. 2
Case Type:  Criminal  Juvenile Dependency/Delinquency  Child Support Enforcement
 Domestic/Sexual/Dating/Repeat Violence or Stalking Injunctions  Unified Family Court
 Dissolution of Marriage  Paternity  Adoption  Other ____________________
Case Number: _______________________________________________
County/State/Court: __________________________________________
Pending  or Closed? If closed, date closed________________
Title of last Court Order/Judgment: ______________________________
Date of Court Order/Judgment: _________________________________
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. 3
Case Type:  Criminal  Juvenile Dependency/Delinquency  Child Support Enforcement
 Domestic/Sexual/Dating/Repeat Violence or Stalking Injunctions  Unified Family Court
 Dissolution of Marriage  Paternity  Adoption  Other ____________________
Case Number: _______________________________________________
County/State/Court: __________________________________________
Pending  or Closed? If closed, date closed________________
Title of last Court Order/Judgment: ______________________________
Date of Court Order/Judgment: _________________________________
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:_______________________________________________
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.
I attest to the truthfulness of the claims made in this affidavit.
Dated: ________________ Signature of Party: __________________________
Printed Name: ___________________________
Street Address: ___________________________
City, State, Zip: ___________________________
Telephone No.: ___________________________
I certify that a copy of the foregoing was mailed or served to the other party listed below on
Date:_______________
Other party:
Name: __________________________
Street Address: __________________________
City, State, Zip: __________________________

Notice of Related Cases page 2

The Family Court Self-Help Program


Self Help File No.: packet_number Receipt & Packet No.: packet_number
Printed on: 4/19/2023 11:38:12 AM
IN THE CIRCUIT COURT OF THE
ELEVENTH JUDICIAL CIRCUIT
IN AND FOR MIAMI-DADE COUNTY,
FLORIDA
FAMILY DIVISION
IN RE:
_____________________________,
Petitioner, CASE NO.:
and
_____________________________,
Respondent.
_______________________________/

SELF-HELP ACKNOWLEDGMENT OF RECEIPT

NOTICE OF LIMITATION OF SELF-HELP SERVICES PROVIDED

THE PERSONNEL IN THIS SELF-HELP PROGRAM ARE NOT ACTING AS YOUR LAWYER
OR PROVIDING LEGAL ADVICE TO YOU.
SELF-HELP PERSONNEL ARE NOT ACTING ON BEHALF OF THE COURT OR ANY JUDGE.
THE PRESIDING JUDGE IN YOUR CASE MAY REQUIRE AMENDMENT OF A FORM OR
SUBSTITUTION OF A DIFFERENT FORM. THE JUDGE IS NOT REQUIRED TO GRANT THE
RELIEF REQUESTED IN A FORM.
THE PERSONNEL IN THIS SELF-HELP PROGRAM CANNOT TELL YOU WHAT YOUR
LEGAL RIGHTS OR REMEDIES ARE, REPRESENT YOU IN COURT, OR TELL YOU HOW
TO TESTIFY IN COURT.
SELF-HELP SERVICES ARE AVAILABLE TO ALL PERSONS WHO ARE OR WILL BE
PARTIES TO A FAMILY CASE.
THE INFORMATION THAT YOU GIVE TO AND RECEIVE FROM SELF-HELP PERSONNEL
IS NOT CONFIDENTIAL AND MAY BE SUBJECT TO DISCLOSURE AT A LATER DATE. IF
ANOTHER PERSON INVOLVED IN YOUR CASE SEEKS ASSISTANCE FROM THIS SELF-
HELP PROGRAM, THAT PERSON WILL BE GIVEN THE SAME TYPE OF ASSISTANCE
THAT YOU RECEIVE.
IN ALL CASES, IT IS BEST TO CONSULT WITH YOUR OWN ATTORNEY, ESPECIALLY IF
YOUR CASE PRESENTS SIGNIFICANT ISSUES REGARDING CHILDREN, CHILD SUPPORT,
ALIMONY, RETIREMENT OR PENSION BENEFITS, ASSETS, OR LIABILITIES.
________I CAN READ ENGLISH.
________I CANNOT READ ENGLISH. THIS NOTICE WAS READ TO ME BY
_________________________{NAME} IN ________________{LANGUAGE} .
SIGNATURE OF LITIGANT___________________________

SIGNATURE OF SELF HELP STAFF_________________________

(General) page 1 of 3

The Family Court Self-Help Program


Self Help File No.: packet_number Receipt & Packet No.: packet_number
Printed on: 4/19/2023 11:38:12 AM
AVISO DE LIMITACION DE SELF-HELP SERVICIOS OFRECIDOS

EL PERSONAL DE ESTE PROGRAMA DE AYUDA PROPIA NO ESTA ACTUANDO COMO SU


ABOGADO NI LE ESTA DANDO CONSEJOS LEGALES.

ESTE PERSONAL NO REPRESENTA NI LA CORTE NI NINGUN JUEZ. EL JUEZ ASIGNADO


A SU CASO PUEDE REQUERIR UN CAMBIO DE ESTA FORMA O UNA FORMA DIFERENTE.
EL JUEZ NO ESTA OBLIGADO A CONCEDER LA REPARACION QUE USTED PIDE EN
ESTA FORMA.

EL PERSONAL DE ESTE PROGRAMA DE AYUDA PROPIA NO LE PUEDE DECIR CUALES


SON SUS DERECHOS NI SOLUCIONES LEGALES, NO PUEDE REPRESENTARLO EN
CORTE, NI DECIRLE COMO TESTIFICAR EN CORTE.

SERVICIOS DE AYUDA PROPIA ESTAN DISPONIBLES A TODAS LAS PERSONAS QUE SON
O SERAN PARTES DE UN CASO FAMILIAR.

LA INFORMACION QUE USTED DA Y RECIBE DE ESTE PERSONAL NO ES


CONFIDENCIAL Y PUEDE SER DESCUBIERTA MAS ADELANTE. SI OTRA PERSONA
ENVUELTA EN SU CASO PIDE AYUDA DE ESTE PROGRAMA, ELLOS RECIBIRAN EL
MISMO TIPO DE ASISTENCIA QUE USTED RECIBE.
EN TODOS LOS CASOS, ES MEJOR CONSULTAR CON SU PROPIO ABOGADO,
ESPECIALMENTE SI SU CASO TRATA DE TEMAS RESPECTO A NINOS, MANTENIMIENTO
ECONOMICO DE NINOS, MANUTENCION MATRIMONIAL, RETIRO O BENEFICIOS DE
PENSION, ACTIVOS U OBLIGA-CIONES.
______ YO PUEDO LEER ESPANOL.
______ YO NO PUEDO LEER ESPANOL. ESTE AVISO FUE LEIDO A MI POR
______________________ {NOMBRE} EN ___________________{IDIOMA} .

Litigant FIRMA___________________________

Self Help FIRMA___________________________

AKIZE RESEPSYON AVI SOU LIMITASYON SÈVIS YO FOUNI YO

PÈSONÈL KI TRAVAY NAN PWOGRAM “SELF-HELP” SA A P AP AJI ANTANKE AVOKA W


OSWA BA W KONSÈY LEGAL.

PÈSONÈL “SELF-HELP” LA P AP AJI LAN NON TRIBINAL LA OSWA LAN NON OKENN JIJ.
JIJ K AP PREZIDE NAN KA W LA KA EGZIJE YON AMANDMAN NAN YON FÒM OUBYEN
KE YO RANPLASE YON FÒM PA YON LÒT FÒM. JIJ LA PA OBLIJE AKÒDE DEMANN KE
OU FÈ LAN FÒM LAN.

PÈSONÈL NAN PWOGRAM “SELF-HELP” SA A PA KA DI W KI KALITE DWA LEGAL


OUBYEN SOLISYON OU GENYEN, NI REPREZANTE W NAN TRIBINAL LA, OUBYEN DI W
KIJAN POU W TEMWAYE NAN TRIBINAL LA.

SÈVIS “SELF-HELP” LA YO DISPONIB POU TOUT MOUN KI SE YON PATI OUBYEN KI


PRAL YON PATI NAN YON KA FAMILYAL .

(General) page 2 of 3

The Family Court Self-Help Program


Self Help File No.: packet_number Receipt & Packet No.: packet_number
Printed on: 4/19/2023 11:38:12 AM
ENFÒMASYON KE W BAY E RESEVWA NAN MEN PÈSONÈL “SELF-HELP” LA PA
KONFIDANSYÈL E PI DEVAN YO KAPAB METE L DEYÒ. SI YON LÒT MOUN KI ENPLIKE
NAN KA W LA CHACHE ASISTANS LAN MEN PWOGRAM “SELF-HELP” LA, MOUN SA A
VA RESEVWA MENM KALITE ASISTANS KE W RESEVWA A.

DETOUTFASON, LI PI BON SI W KONSILTE PWÒP AVOKA W, SITOU SI KA W LA


GENYEN PWOBLÈM ENPÒTAN LADAN L KI GEN RAPÒ AK TIMOUN, LAJAN POU OKIPE
TIMOUN, PANSYON ALIMANTÈ, BENEFIS POU RETRÈT OSWA PANSYON, BYEN OSWA
DÈT.

________MWEN KAPAB LI ANGLÈ.


________MWEN PA KAPAB LI ANGLÈ. SE
_________________________{NON MOUN LAN} KI TE LI AVI SA A POU MWEN AN
________________{LANG} .
SIYATI PLEYAN AN___________________________

SIYATI ANPLWAYE “SELF HELP” LA_________________________

(General) page 3 of 3

The Family Court Self-Help Program


Self Help File No.: packet_number Receipt & Packet No.: packet_number
Printed on: 4/19/2023 11:38:12 AM
IN THE CIRCUIT COURT OF THE
ELEVENTH JUDICIAL CIRCUIT
IN AND FOR MIAMI-DADE COUNTY,
FLORIDA
FAMILY DIVISION
IN RE:

_____________________________,
Petitioner, CASE NO.:
and
_____________________________,
Respondent.
_______________________________/

DESIGNATION OF CURRENT MAILING AND E-MAIL ADDRESS


(Petitioner)

I, {full legal name}, _________________________________________, being sworn, certify that:

MAILING ADDRESS:
My current mailing address is:
{Street or Post Office Box}_______________________________________________________,
{City}, ___________________________________, {State}, _____________,
{Zip}_____________.
{Telephone No.} _____________

E-MAIL ADDRESS:
{Do not provide an e-mail address unless you choose to serve and receive all documents in the
future only by e-mail. If you are a self-represented litigant (appearing without an attorney), you
are not required to serve or receive documents by electronic mail (e-mail); however, once you
designate an e-mail address, that address will be the exclusive means of serving and receiving
documents. Once you choose to serve and receive documents by e-mail, you cannot change your
decision.}
I wish to designate the following e-mail address(es) for the purposes of serving and receiving
documents:
Email address:___________________________________________________________________

I understand that I must keep the clerk’s office and the opposing party or parties notified of
my current mailing and e-mail address(es) and that all future papers in this lawsuit will be
served at the address(es) on record at the clerk’s office.
I certify that a copy of this document was _____ e-mailed _____ mailed _____ faxed and mailed
_____ hand-delivered to the person(s) listed below on {date}__________________________.

The Family Court Self-Help Program


Self Help File No.: packet_number Receipt & Packet No.: packet_number
Printed on: 4/19/2023 11:38:12 AM
Other party or his/her attorney:
Name: _____________________________
Address: ____________________________
City, State, Zip: _______________________
Designated E-mail Address(es): ___________
__________________________________

_____________________________________________
Signature of Party (Petitioner)

STATE OF FLORIDA)
COUNTY OF MIAMI-DADE)
Sworn to or affirmed and signed before me on ________________ by
________________________________.

___________________________________
NOTARY PUBLIC or DEPUTY CLERK
 Personally known

 Produced identification: ___________________________________________

The Family Court Self-Help Program


Self Help File No.: packet_number Receipt & Packet No.: packet_number
Printed on: 4/19/2023 11:38:12 AM
IN THE CIRCUIT COURT OF THE
ELEVENTH JUDICIAL CIRCUIT
IN AND FOR MIAMI-DADE COUNTY,
FLORIDA
FAMILY DIVISION
IN RE:

_____________________________,
Petitioner, CASE NO.:
and
_____________________________,
Respondent.
_______________________________/

DESIGNATION OF CURRENT MAILING AND E-MAIL ADDRESS


(Respondent)

I, {full legal name}, _________________________________________, being sworn, certify that:

MAILING ADDRESS:
My current mailing address is:
{Street or Post Office Box}_______________________________________________________,
{City}, ___________________________________, {State}, _____________,
{Zip}_____________.
{Telephone No.} _____________

E-MAIL ADDRESS:
{Do not provide an e-mail address unless you choose to serve and receive all documents in the
future only by e-mail. If you are a self-represented litigant (appearing without an attorney), you
are not required to serve or receive documents by electronic mail (e-mail); however, once you
designate an e-mail address, that address will be the exclusive means of serving and receiving
documents. Once you choose to serve and receive documents by e-mail, you cannot change your
decision.}
I wish to designate the following e-mail address(es) for the purposes of serving and receiving
documents:
Email address:___________________________________________________________________

I understand that I must keep the clerk’s office and the opposing party or parties notified of
my current mailing and e-mail address(es) and that all future papers in this lawsuit will be
served at the address(es) on record at the clerk’s office.
I certify that a copy of this document was _____ e-mailed _____ mailed _____ faxed and mailed
_____ hand-delivered to the person(s) listed below on {date}__________________________.

The Family Court Self-Help Program


Self Help File No.: packet_number Receipt & Packet No.: packet_number
Printed on: 4/19/2023 11:38:12 AM
Other party or his/her attorney:
Name: _____________________________
Address: ____________________________
City, State, Zip: _______________________
Designated E-mail Address(es): ___________
__________________________________

_____________________________________________
Signature of Party (Respondent)

STATE OF FLORIDA)
COUNTY OF MIAMI-DADE)
Sworn to or affirmed and signed before me on ________________ by
________________________________.

___________________________________
NOTARY PUBLIC or DEPUTY CLERK
 Personally known

 Produced identification: ___________________________________________

The Family Court Self-Help Program


Self Help File No.: packet_number Receipt & Packet No.: packet_number
Printed on: 4/19/2023 11:38:12 AM

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