Temporary Custody
Temporary Custody
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
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
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.
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.
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 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………………..
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.
Example: To make an appointment for a Post Judgment Modification packet, you will
select First-Time Visit Temporary Custody
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 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
• 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
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
FAMILY DIVISION
IN THE INTEREST OF
__________________________________,
Children CASE NO.:
__________________________________,
Petitioner,
and
__________________________________,
Respondent,
__________________________________,
Respondent.
1. This is an action for temporary custody pursuant to Chapter 751, Florida Statutes.
Page 1 of 5
Form A-5
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.
6. The residence and post office address of the Petitioner is: ____________
________________________________________________________________ .
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.
Page 2 of 5
Form A-5
____________
____________
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:
______________________________________________________________________
______________________________________________________________________
Page 3 of 5
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
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.
STATE OF FLORIDA)
COUNTY OF MIAMI-DADE)
___________________________________
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} ___________.
Page 5 of 5
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.
□
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 __________________________________________
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:
Enclosed please find a self-addressed, stamped envelope. Thank you for your cooperation.
Sincerely:
STATE OF FLORIDA)
COUNTY OF MIAMI-DADE)
___________________________________
NOTARY PUBLIC or DEPUTY CLERK
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.
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.
STATE OF FLORIDA)
COUNTY OF MIAMI-DADE)
___________________________________
NOTARY PUBLIC or DEPUTY CLERK
_____ Personally known
_____ Produced identification: ___________________________________________
FAMILY DIVISION
IN THE INTEREST OF
__________________________________,
Children CASE NO.:
__________________________________,
Petitioner,
and
__________________________________,
Respondent,
__________________________________,
Respondent.
AFFIDAVIT OF DILIGENT
SEARCH AND INQUIRY
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):
_____ 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.
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.
STATE OF FLORIDA)
COUNTY OF MIAMI-DADE)
___________________________________
NOTARY PUBLIC or DEPUTY CLERK
Personally known
Produced identification: ___________________________________________
__________________________________,
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 _______.
FAMILY DIVISION
IN THE INTEREST OF
__________________________________,
Children CASE NO.:
__________________________________,
Petitioner,
and
__________________________________,
Respondent,
__________________________________,
Respondent.
MOTION__________________________
___________________________________
3.
4.
5.
6.
7.
I certify that a copy of the foregoing was mailed to the person listed below on
{date} ________________________:
STATE OF FLORIDA)
COUNTY OF MIAMI-DADE)
___________________________________
NOTARY PUBLIC or DEPUTY CLERK
:FAMILY DIVISION
IN THE INTEREST OF
__________________________________,
Children CASE NO.:
__________________________________,
Petitioner,
and
__________________________________,
Respondent,
__________________________________,
Respondent. REQUEST FOR HEARING
__________________________________,
Children CASE NO.:
__________________________________,
Petitioner,
and
__________________________________,
Respondent,
__________________________________,
Respondent.
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).
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.
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 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).
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.
DATED: _________________
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
FAMILY DIVISION
, CASE NO.:
Petitioner,
and
______ / 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
______ / Present*
______ / _______
______ / ______
______ /
______
______ / ______
______ / Present*
______ / _______
______ / ______
______ /
______
______ / ______
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 _________________________
_________________________________
Children
__________________________________,
Petitioner,
and
__________________________________,
Respondent,
__________________________________,
Respondent.
.
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
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.
STATE OF FLORIDA)
COUNTY OF MIAMI-DADE)
___________________________________
NOTARY PUBLIC or DEPUTY CLERK
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}
________________________
_________________________________
Children
__________________________________,
Petitioner,
and
__________________________________,
Respondent,
__________________________________,
Respondent.
.
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
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.
STATE OF FLORIDA)
COUNTY OF MIAMI-DADE)
___________________________________
NOTARY PUBLIC or DEPUTY CLERK
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} ________________________
FAMILY DIVISION
IN THE INTEREST OF
__________________________________,
Children CASE NO.:
__________________________________,
Petitioner,
and
__________________________________,
Respondent,
__________________________________,
Respondent,
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___________________________
(General) page 1 of 3
SERVICIOS DE AYUDA PROPIA ESTAN DISPONIBLES A TODAS LAS PERSONAS QUE SON
O SERAN PARTES DE UN CASO FAMILIAR.
Litigant FIRMA___________________________
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.
(General) page 2 of 3
(General) page 3 of 3
_____________________________,
Petitioner, CASE NO.:
and
_____________________________,
Respondent.
_______________________________/
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}__________________________.
_____________________________________________
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
_____________________________,
Petitioner, CASE NO.:
and
_____________________________,
Respondent.
_______________________________/
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}__________________________.
_____________________________________________
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