IMPORTANT - Pasco Clerk · imminent danger of becoming a victim of domestic violence, ... Supplemental Affidavit in Support of Petition for Injunction for Protection Against Domestic

**IMPORTANT** It is strongly recommended that you file your paperwork DURING THE MORNING BUSINESS HOURS to allow

sufficient time during the day for the court to review your request. Pursuant to Administrative Order number 2010-

044, all Petitions for Protective Injunctions must be filed in the Clerk's office before 4:00pm for same day processing..

For after hour emergency services, please contact · your respective Domestic Violence Center:

New Port Richey: Salvation Army Domestic Violence Center

PO Box 5517, Hudson, FL 34674 727-856-5797

Dade City: Sunrise Domestic Violence Center

POBox928 Dade City, FL 33526

352-521-3120

Instructions for Florida Supreme Court Approved Family Law Form 12.980(a), Petition for Injunction for Protection Against Domestic Violence (11/15)

INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW FORM 12.980(a)

PETITION FOR INJUNCTION FOR PROTECTION AGAINST DOMESTIC VIOLENCE (11/15)

When should this form be used?

If you are a victim of any act of domestic violence or have reasonable cause to believe that you are in imminent danger of becoming a victim of domestic violence, you can use this form to ask the court for a protective order prohibiting domestic violence. Because you are making a request to the court, you are called the petitioner. The person whom you are asking the court to protect you from is called the respondent. Domestic violence includes: assault, aggravated assault, battery, aggravated battery, sexual assault, sexual battery, stalking, aggravated stalking, kidnapping, false imprisonment, or any other criminal offense resulting in physical injury or death to petitioner by any of petitioner’s family or household members. In determining whether you have reasonable cause to believe you are in imminent danger of becoming a victim of domestic violence, the court must consider all relevant factors alleged in the petition, including, but not limited to the following:

1. The history between the petitioner and the respondent, including threats, harassment, stalking, and physical abuse.

2. Whether the respondent has attempted to harm the petitioner or family members or individuals closely associated with the petitioner.

3. Whether the respondent has threatened to conceal, kidnap, or harm the petitioner’s child or children.

4. Whether the respondent has intentionally injured or killed a family pet.

5. Whether the respondent has used, or has threatened to use, against the petitioner any weapons such as guns or knives.

6. Whether the respondent has physically restrained the petitioner from leaving the home or calling law enforcement.

7. Whether the respondent has a criminal history involving violence or the threat of violence.

8. The existence of a verifiable order of protection issued previously or from another jurisdiction.

9. Whether the respondent has destroyed personal property, including, but not limited to, telephones or other communications equipment, clothing, or other items belonging to the petitioner.

10. Whether the respondent engaged in any other behavior or conduct that leads the petitioner to have reasonable cause to believe that he or she is in imminent danger of becoming a victim of domestic violence.

The domestic violence laws only apply to your situation if the respondent is your spouse, former spouse, related to you by blood or marriage, living with you now or has lived with you in the past (if you are or were living as a family), or the other parent of your child(ren) whether or not you have ever been married or ever lived together. With the exception of persons who have a child in common, the family or household members must be currently residing together or have in the past resided together in the same


single dwelling unit. If the respondent is not one of the above, you should look at Petition for Injunction for Protection Against Repeat Violence, Florida Supreme Court Approved Family Law Form 12.980(f), to determine if your situation will qualify for an injunction for protection against repeat violence, or Petition for Injunction for Protection Against Dating Violence, Florida Supreme Court Approved Family Law Form 12.980(n), to determine if your situation will qualify for an injunction for protection against dating violence, or Petition for Injunction for Protection Against Sexual Violence, Florida Supreme Court Approved Family Law Form 12.980(q), to determine if your situation will qualify for an injunction for protection against sexual violence.

If you are under the age of eighteen and you have never been married or had the disabilities of nonage removed by a court, then one of your parents, custodians, or your legal guardian must sign this petition with you.

This form should be typed or printed in black ink. You should complete this form (giving as much detail as possible) and sign it in front of a notary public or the clerk of the circuit court in the county where you live. The clerk will take your completed petition to a judge. You should keep a copy for your records. If you have any questions or need assistance completing this form, the clerk or family law intake staff will help you.

What should I do if the judge grants my petition? If the facts contained in your petition convince the judge that you are a victim of domestic violence or that an imminent danger of domestic violence exists, the judge will sign either an immediate Temporary Injunction for Protection Against Domestic Violence with Minor Child(ren), Florida Supreme Court Approved Family Law Form 12.980(c)(1) or an immediate Temporary Injunction for Protection Against Domestic Violence without Minor Child(ren), Florida Supreme Court Approved Family Law Form 12.980(c)(2). A temporary injunction is issued without notice to the respondent. The clerk will give your petition, the temporary injunction, and any other papers filed with your petition to the sheriff or other law enforcement officer for personal service on the respondent. The temporary injunction will take effect immediately after the respondent is served with a copy of it. It lasts until a full hearing can be held or for a period of 15 days, whichever comes first. The court may extend the temporary injunction beyond 15 days for a good reason, which may include failure to obtain service on the respondent. The temporary injunction is issued ex parte. This means that the judge has considered only the information presented by one side-- YOU. The temporary injunction gives a date that you must appear in court for a hearing. At that hearing, you will be expected to testify about the facts in your petition. The respondent will be given the opportunity to testify at this hearing, also. At the hearing, the judge will decide whether to issue either a Final Judgment of Injunction for Protection Against Domestic Violence with Minor Child(ren)(After Notice), Florida Supreme Court Approved Family Law Form 12.980(d)(1), or a Final Judgment of Injunction for Protection Against Domestic Violence without Minor Child(ren)(After Notice), Florida Supreme Court Approved Family Law Form 12.980(d)(2). Either of these final judgments will remain in effect for a specific time period or until modified or dissolved by the court. If either you or the respondent do not appear at the final hearing, the temporary injunction may be continued in force, extended, or dismissed, and/or additional orders may be granted, including entry of a permanent injunction and the imposition of court costs. You and respondent will be bound by the terms of any injunction issued at the final hearing.


IF EITHER YOU OR RESPONDENT DO NOT APPEAR AT THE FINAL HEARING, YOU WILL BOTH BE BOUND BY THE TERMS OF ANY INJUNCTION ISSUED IN THIS MATTER. If the judge signs a temporary or final injunction, the clerk will provide you with the necessary copies. Make sure that you keep one certified copy of the injunction with you at all times!

What can I do if the judge denies my petition?

If your petition is denied solely on the grounds that it appears to the court that no imminent danger of domestic violence exists, the court will set a full hearing, at the earliest possible time, on your petition, unless you request that no hearing be set. The respondent will be notified by personal service of your petition and the hearing. If your petition is denied, you may: amend your petition by filing a Supplemental Affidavit in Support of Petition for Injunction for Protection Against Domestic Violence, Repeat or Dating Violence, Florida Family Law Form 12.980 (g); attend the hearing and present facts that support your petition; and/or dismiss your petition.

Where can I look for more information? Before proceeding, you should read General Information for Self-Represented Litigants found at the beginning of these forms. The words that are in bold underline are defined in that section. The clerk of the circuit court or family law intake staff will help you complete any necessary domestic violence forms and can give you information about local domestic violence victim assistance programs, shelters, and other related services. You may also call the Domestic Violence Hotline at 1-800-500-1119. For further information, see Chapter 741, Florida Statutes, and Rule 12.610, Florida Family Law Rules of Procedure.

IMPORTANT INFORMATION REGARDING E-FILING The Florida Rules of Judicial Administration now require that all petitions, pleadings, and documents be filed electronically except in certain circumstances. Self-represented litigants may file petitions or other pleadings or documents electronically; however, they are not required to do so. If you choose to file your pleadings or other documents electronically, you must do so in accordance with Florida Rule of Judicial Administration 2.525, and you must follow the procedures of the judicial circuit in which you file. The rules and procedures should be carefully read and followed.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION

After the initial service of process of the petition or supplemental petition by the Sheriff or certified process server, the Florida Rules of Judicial Administration now require that all documents required or permitted to be served on the other party must be served by electronic mail (e-mail) except in certain circumstances. You must strictly comply with the format requirements set forth in the Rules of Judicial Administration. If you elect to participate in electronic service, which means serving or receiving pleadings by electronic mail (e-mail), or through the Florida Courts E-Filing Portal, you must review Florida Rule of Judicial Administration 2.516. You may find this rule at www.flcourts.org through the link to the Rules of Judicial Administration provided under either Family Law Forms: Getting Started, or Rules of Court in the A-Z Topical Index.

http://www.flcourts.org/


SELF-REPRESENTED LITIGANTS MAY SERVE DOCUMENTS BY E-MAIL; HOWEVER, THEY ARE NOT REQUIRED TO DO SO. If a self-represented litigant elects to serve and receive documents by e-mail, the procedures must always be followed once the initial election is made. To serve and receive documents by e-mail, you must designate your e-mail addresses by using the Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family Law Form 12.915, and you must provide your e-mail address on each form on which your signature appears. Please CAREFULLY read the rules and instructions for: Certificate of Service (General), Florida Supreme Court Approved Family Law Form 12.914; Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family Law Form 12.915; and Florida Rule of Judicial Administration 2.516.

Special notes... With this form you may also need to file the following:

Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida Supreme Court Approved Family Law Form 12.902(d), must be completed and filed if you are asking the court to determine issues with regard to your parenting plan or time-sharing for a minor child(ren).

Parenting plan means a document created to govern the relationship between the parents relating to the decisions that must be made regarding the minor child(ren) and must contain a time-sharing schedule for the parents and child(ren). The issues concerning the minor child(ren) may include, but are not limited to, the child(ren)’s education, health care, and physical, social, and emotional well-being. In creating the plan, all circumstances between the parents, including their historic relationship, domestic violence, and other factors must be taken into consideration. The Parenting Plan shall be developed and agreed to by the parents and approved by a court, or, established by the court, with or without the use of a court- ordered parenting plan recommendation. If the parents cannot agree, or if the parents agreed to a plan that is not approved by the court, a Parenting Plan shall established by the court. “Time-sharing schedule” means a timetable that must be included in the Parenting Plan that specifies the time, including overnights and holidays, that a minor child will spend with each parent. If developed and agreed to by the parents of a minor child, it must be approved by the court. If the parents cannot agree, of if their agreed-upon schedule is not approved by the court, the schedule shall be established by the court.

Notice of Social Security Number, Florida Supreme Court Approved Family Law Form 12.902(j), must be completed and filed if you are asking the court to determine issues of temporary child support.

Family Law Financial Affidavit, Florida Family Law Rules of Procedure Form 12.902(b) or (c), must be completed and filed if you are seeking temporary alimony or temporary child support.

Child Support Guidelines Worksheet, Florida Family Law Rules of Procedure Form 12.902(e), MUST be filed with the court at or prior to a hearing to establish or modify child support.

Additionally, if you fear that disclosing your address to the respondent would put you in danger, you should complete a Request for Confidential Filing of Address, Florida Supreme Court Approved Family Law Form 12.980(h), and file it with the clerk of the circuit court and write confidential in the space provided on the petition.

Florida Supreme Court Approved Family Law Form 12.980(a), Petition for Injunction for Protection Against Domestic Violence (11/15)

IN THE CIRCUIT COURT OF THE _______________________ JUDICIAL CIRCUIT, IN AND FOR ________________________ COUNTY, FLORIDA

Case No.: ___________________________

___

Division: __________________________________________________________________________________

________

__________________________________, Petitioner,

and

__________________________________,

Respondent,

PETITION FOR INJUNCTION FOR PROTECTION AGAINST DOMESTIC VIOLENCE

I, {full legal name} , being sworn, certify that the following statements are true: SECTION I. PETITIONER (This section is about you. It must be completed. However, if you fear that disclosing your address to the respondent would put you in danger, you should complete and file a Request for Confidential Filing of Address, Florida Supreme Court Approved Family Law Form 12.980(h), and write confidential in the space provided on this form for your address and telephone number.)

1. Petitioner’s current address is: {street address} ________________________________________

{city, state and zip code} __________________________________________________________ Telephone Number: {area code and number} __________________________________________ Physical description of Petitioner: ____________________________________________________ Race: _____ Sex: Male _____ Female _____ Date of Birth: _______________________________

2. Petitioner’s attorney’s name, address, and telephone number is: _________________________ ______________________________________________________________________________ (If you do not have an attorney, write none.)

SECTION II. RESPONDENT (This section is about the person you want to be protected from. It must be completed.)

1. Respondent’s current address is: {street address, city, state, and zip code} ___________________ _______ ______________________________________________________________________ Respondent’s Driver’s License number is: {if known} ___________________________________


2. Respondent is: {Indicate all that apply}

a. _____ the spouse of Petitioner. Date of Marriage:

b. _____ the former spouse of Petitioner. Date of Marriage: Date of Dissolution of Marriage:

c. _____ related by blood or marriage to Petitioner. Specify relationship:

d. _____ a person who is or was living in one home with Petitioner, as if a family.

e. _____ a person with whom Petitioner has a child in common, even if Petitioner and Respondent never were married or living together.

3. Petitioner has known Respondent since {date}

4. Respondent’s last known place of employment:

Employment address:

Working hours:

5. Physical description of Respondent: Race: Sex: Male _____ Female _____ Date of Birth: Height: Weight: Eye Color: Hair Color:

Distinguishing marks or scars:

Vehicle: (make/model) Color: _____ Tag Number:

6. Other names Respondent goes by (aliases or nicknames):

7. Respondent’s attorney’s name, address, and telephone number is:

(If you do not know whether Respondent has an attorney, write unknown. If Respondent does not have an attorney, write none.)

SECTION III. CASE HISTORY AND REASON FOR SEEKING PETITION (This section must be completed.)

1. Has Petitioner ever received or tried to get an injunction for protection against domestic violence against Respondent in this or any other court? _____ Yes _____ No If yes, what happened in that case? {Include case number, if known}

______________________________________________________________________________

______________________________________________________________________________

2. Has Respondent ever received or tried to get an injunction for protection against domestic violence against Petitioner in this or any other court? _____Yes _____ No If yes, what happened in that case? {Include case number, if known}

______________________________________________________________________________


______________________________________________________________________________

3. Describe any other court case that is either going on now or that happened in the past, including a dissolution of marriage, paternity action, or child support enforcement action, between Petitioner and Respondent {Include city, state, and case number, if known}:

______________________________________________________________________________

______________________________________________________________________________

4. Petitioner is either a victim of domestic violence or has reasonable cause to believe he or she is

in imminent danger of becoming a victim of domestic violence because respondent has: {mark all

sections that apply and describe in the spaces below the incidents of violence or threats of violence,

specifying when and where they occurred, including, but not limited to, locations such as a

home, school, place of employment, or time-sharing exchange}

a. committed or threatened to commit domestic violence defined in section 741.28,

Florida Statutes, as any assault, aggravated assault, battery, aggravated battery, sexual

assault, sexual battery, stalking, aggravated stalking, kidnapping, false imprisonment, or any

criminal offense resulting in physical injury or death of one family or household member by

another. With the exception of persons who are parents of a child in common, the family or

household members must be currently residing or have in the past resided together in the

same single dwelling unit.

b. previously threatened, harassed, stalked, or physically abused the petitioner.

c. attempted to harm the petitioner or family members or individuals closely

associated with the petitioner.

d. threatened to conceal, kidnap, or harm the petitioner's child or children. e. intentionally injured or killed a family pet. f. used, or has threatened to use, against the petitioner any weapons such as

guns or knives.

g. physically restrained the petitioner from leaving the home or calling law enforcement.

h. a criminal history involving violence or the threat of violence (if known). i. another order of protection issued against him or her previously or from

another jurisdiction (if known).

j. destroyed personal property, including, but not limited to, telephones or other

communication equipment, clothing, or other items belonging to the petitioner.

k. engaged in any other behavior or conduct that leads the petitioner to have

reasonable cause to believe he or she is in imminent danger of becoming a victim of

domestic violence.

Below is a brief description of the latest act of violence or threat of violence that causes

Petitioner to honestly fear imminent domestic violence by Respondent.

(Use additional sheets if necessary.)


On {date} , at {location} ,

Respondent:

_____ Please indicate here if you are attaching additional pages to continue these facts.

5. Additional Information

{Indicate all that apply} a. _____ Other acts or threats of domestic violence as described on attached sheet.

b. _____ This or other acts of domestic violence have been previously reported to {person or

agency}: ____________________________________________________________________

c. _____ Respondent owns, has, and/or is known to have guns or other weapons.

Describe weapon(s):

d. _____ Respondent has a drug problem.

e. _____ Respondent has an alcohol problem.

f. _____ Respondent has a history of mental health problems. If checked, answer the

following, if known:

Has Respondent ever been the subject of a Baker Act proceeding? _____ Yes _____ No Is Respondent supposed to take medication for mental health problems? _____ Yes _____ No If yes, is Respondent currently taking his/her medication? _____ Yes _____ No

SECTION IV. TEMPORARY EXCLUSIVE USE AND POSSESSION OF HOME (Complete this section only if

you want the Court to grant you temporary exclusive use and possession of the home that you share with

the Respondent.)


1. Petitioner claims the following about the home that Petitioner and Respondent share or that

Petitioner left because of domestic violence:

{Indicate all that apply}

a. _____ Petitioner needs the exclusive use and possession of the home that the parties share at

{street address} ,

{city, state, zip code} .

b. _____ Petitioner cannot get another safe place to live because: ______ ______________

c._____ If kept out of the home, Respondent has the money to get other housing or may live

without money at {street address} ,

{city, state, zip code} .

2. The home is:

{Choose one only}

a. owned or rented by Petitioner and Respondent jointly.

b. solely owned or rented by Petitioner.

c. solely owned or rented by Respondent.

SECTION V. TEMPORARY PARENTING PLAN WITH TEMPORARY TIME-SHARING SCHEDULE FOR MINOR CHILD(REN) (Complete this section only if you are asking the court to provide a temporary parenting plan,

including a temporary time-sharing schedule with regard to, the minor child or children of the parties

which might involve prohibiting or limiting time-sharing or requiring that it be supervised by a third party.

You must be the natural parent, adoptive parent, or guardian by court order of the minor child(ren). If

you are asking the court to provide a temporary parenting plan, including a temporary time-sharing

schedule with regard to, the minor child or children of the parties which might involve prohibiting or

limiting time-sharing or requiring that it be supervised by a third party, you must also complete and file a

Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit, Florida Supreme Court

Approved Family Law Form 12.902(d).)

Note: If the paternity of the minor child(ren) listed below has not been established through either

marriage or court order, the Court may deny a request to provide a temporary parenting plan, including

a temporary time-sharing schedule with regard to, the minor child or children, and/or a request for


child support.

1. Petitioner is the natural parent, adoptive parent, or guardian by court order of the minor

child(ren) whose name(s) and age(s) is (are) listed below.

Name Birth date

2. The minor child(ren) for whom Petitioner is asking the court to provide a temporary parenting

plan, including a temporary time-sharing schedule with regard to:

{Choose one only} a._____ saw the domestic violence described in this petition happen. b. _____ were at the place where the domestic violence happened but did not see it. c. _____ were not there when the domestic violence happened this time but have seen previous acts of domestic violence by Respondent. d. _____ have not witnessed domestic violence by Respondent.

3. Name any other minor child(ren) who were there when the domestic violence happened. Include child(ren)’s name, age, and parents’ names.

4. Temporary Parenting Plan and Temporary Time-Sharing Schedule

{Indicate all that apply} a. Petitioner requests that the Court provide a temporary parenting plan, including a temporary time sharing schedule with regard to, the minor child or children of the parties, as follows:

b. Petitioner requests that the Court order supervised exchange of the minor child(ren) or

exchange through a responsible person designated by the Court. The following person is

suggested as a responsible person for purposes of such exchange. {Explain}:


c. Petitioner requests that the Court limit time-sharing by Respondent with the minor

child(ren). {Explain}:

d. Petitioner requests that the Court prohibit time-sharing by Respondent with the minor

child(ren) because Petitioner genuinely fears that Respondent imminently will abuse, remove, or

hide the minor child(ren) from Petitioner. {Explain}:

e. Petitioner requests that the Court allow only supervised time-sharing by Respondent

with the minor child(ren). . {Explain}:

Supervision should be provided by a Family Visitation Center, or other

(specify):

SECTION VI. TEMPORARY SUPPORT (Complete this section only if you are seeking financial support

from the Respondent. You must also complete and file a Family Law Financial Affidavit, Florida Family

Law Rules of Procedure Form 12.902(b) or (c), and Notice of Social Security Number, Florida Supreme

Court Approved Family Law Form 12.902(j), if you are seeking child support. A Child Support Guidelines

Worksheet, Florida Family Law Rules of Procedure Form 12.902(e), must be filed with the court at or prior

to a hearing to establish or modify child support.)

{Indicate all that apply}

1. Petitioner claims a need for the money he or she is asking the Court to make

Respondent pay, and that Respondent has the ability to pay that money.

2. Petitioner requests that the Court order Respondent to pay the following temporary alimony to Petitioner. (Petitioner must be married to Respondent to ask for temporary alimony.) Temporary Alimony Requested $ every: week other week month.

3. Petitioner requests that the Court order Respondent to pay the following temporary

child support to Petitioner. (The Respondent must be the natural parent, adoptive parent, or guardian by court order of the minor child(ren) for the court to order the Respondent to pay child support.)Temporary child support is requested in the amount of $ every: week other week month.


SECTION VII. INJUNCTION (This section summarizes what you are asking the Court to include in the injunction. This section must be completed.)

1. Petitioner asks the Court to enter a TEMPORARY INJUNCTION for protection against domestic

violence that will be in place from now until the scheduled hearing in this matter.

2. Petitioner asks the Court to enter, after a hearing has been held on this petition, a final judgment

on injunction prohibiting Respondent from committing any acts of domestic violence against

Petitioner and:

a. prohibiting Respondent from going to or within 500 feet of any place the Petitioner lives; b. prohibiting Respondent from going to or within 500 feet of the Petitioner’s place(s) of

employment or school; the address of Petitioner’s place(s) of employment or

school is:

____________________________________________________________________________

____________________________________________________________________________

c. prohibiting Respondent from contacting Petitioner by mail, by telephone, through another

person, or in any other manner;

d. prohibiting Respondent from knowingly and intentionally going to or within 100 feet of

Petitioner’s motor vehicle.

e. prohibiting Respondent from defacing or destroying Petitioner’s personal property. {Indicate all that apply}

f. prohibiting Respondent from going to or within 500 feet of the following place(s)

Petitioner or Petitioner’s minor child(ren) must go often {include address}:

____________________________________________________________________________ ____________________________________________________________________________

g. granting Petitioner temporary exclusive use and possession of the home Petitioner and Respondent share;

h. granting Petitioner on a temporary basis 100% of the time sharing with the parties’ minor child(ren);

i. establishing a temporary parenting plan including a temporary time-sharing schedule for the parties’ minor child(ren);

j. granting temporary alimony for Petitioner; k. granting temporary child support for the minor child(ren);


l. ordering Respondent to participate in treatment, intervention, and/or counseling

services; m. referring Petitioner to a certified domestic violence center; and any other terms the

Court deems necessary for the protection of Petitioner and/or Petitioner’s child(ren), including

injunctions or directives to law enforcement agencies, as provided in Section 741.30, Florida

Statutes.

I UNDERSTAND THAT BY FILING THIS PETITION, I AM ASKING THE COURT TO HOLD A HEARING ON THIS

PETITION, THAT BOTH RESPONDENT AND I WILL BE NOTIFIED OF THE HEARING, AND THAT I MUST

APPEAR AT THE HEARING. I UNDERSTAND THAT IF EITHER RESPONDENT OR I FAIL TO APPEAR AT THE

HEARING, WE WILL BE BOUND BY THE TERMS OF ANY INJUNCTION ISSUED AT THAT HEARING.

I HAVE READ EVERY STATEMENT MADE IN THIS PETITION, AND EACH STATEMENT IS TRUE AND

CORRECT. I UNDERSTAND THAT THE STATEMENTS MADE IN THIS PETITION ARE BEING MADE UNDER

PENALTY OF PERJURY, PUNISHABLE AS PROVIDED IN SECTION 837.02, FLORIDA STATUTES.

___________________ (initials) Dated:

Signature of Petitioner

STATE OF FLORIDA

COUNTY OF Sworn to or affirmed and signed before me on by NOTARY PUBLIC or DEPUTY CLERK

{Print, type, or stamp commissioned name of notary or clerk.}

_ Personally known

_ Produced identification

Type of identification produced

Petitioner Waiver-Non Waiver 06-10-13

IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL CIRCUIT

OF THE STATE OF FLORIDA IN AND FOR PINELLAS/PASCO COUNTY

CIRCUIT CIVIL NO:_________________________________

IN RE:

__________________________________, Petitioner and ___________________________________, Respondent.

PETITIONER’S WAIVER OR NON-WAIVER OF RETURN HEARING

I, ________________________________________________, the Petitioner herein, have filed a Petition for

Protection Against Domestic Violence Dating Violence Repeat Violence ☐ Stalking/Cyberstalking,or Sexual

Violence. I understand that, after reviewing the Petition, the court may:

a.) Issue a temporary injunction and set the case for hearing with notice to the Respondent, or

b.) Not issue a temporary injunction and set the case for hearing with notice to the Respondent, or

c.) Deny the temporary injunction and not set the case for hearing

Petitioner: Please initial either Paragraph A or B below: _______ A. If the court does not issue a temporary injunction for protection, I request that a hearing be set and understand

that notice of the hearing and copy of the Petition for Injunction will be provided to the Respondent.

OR _______ B. If the court does not issue a temporary injunction for protection, I do NOT want a return hearing to be

scheduled. I do NOT want the Respondent to be served with a notice of hearing or a copy of the Petition for Injunction

without a temporary injunction for protection in place. I waive my right under F.S§741.30(5)(b) to have this case set for

hearing. I further understand that nothing herein affects my right to amend my petition. I have signed this waiver freely and

voluntarily.

_____________________________________________ ____________________________________

Signature of Petitioner Date

Printed Name: _________________________________

Mailing Address. All parties shall notify the Clerk of the Court of any change in his or her mailing address within 10 days of

the change. All Petitioners may submit and update confidential addresses at the Pasco Clerk of Court or contact the Florida

Attorney General’s Office Address Confidentiality Program.

Name: ________________________________________ Race: __________ Sex: _______ DOB: ____________

Height: __________ Weight: __________ Hair Color: ______________ Eye Color: _____________

Is the respondent currently in jail? If yes, which county? ________________________

Address: ___________________________________________________

Name: ________________________________________ Race: __________ Sex: _______ DOB: ____________

Address: ___________________________________________________

How do you know the respondent? _____________________________________________________________

Have you ever lived with the respondent? o Yes o No Phone #: ____________________________

Is an Interpreter needed? If so, which language and for whom? _________________________________________

Pasco Sheriff’s OfficePROTECTIVE INJUNCTION WORKSHEET

The fields in BOLD are required by the Florida Department of Law Enforcement and the FBI for injunctions to be included in State and National databases. Without this information, the injunction may not be able to be served because the correct identity of the respondent may not be able to be confirmed. Also, without necessary information, it may not be able to be entered and therefore not recognized throughout the USA. Please fill out the form completely.

Case Number: _____________________________

PETITIONER’S INFORMATION

First Middle Last

Street City Zip Code

OBO INFORMATION

First Middle Last

First Middle Last

First Middle Last

2nd OBO

3rd OBO

RESPONDENT’S INFORMATION

First Middle Last (Or age, only if DOB unknown)

(Please completely spell out hair and eye colors)

PSO# 30358 (Rev. 8/16) Page 1 of 2


Name: ________________________________________ Race: __________ Sex: _______ DOB: ____________

Name: ________________________________________ Race: __________ Sex: _______ DOB: ____________

Name: ________________________________________ Race: __________ Sex: _______ DOB: ____________

Pasco Sheriff’s OfficePROTECTIVE INJUNCTION WORKSHEET

Address: ___________________________________________________

Address: ___________________________________________________

Phone Number: ____________________ Alternate Number: ____________________

(Continued)

Other Possible Locations Or Hang Outs

PSO# 30358 (Rev. 8/16) Page 2 of 2

Year: _______ Make: ____________________ Model: ___________________ Color: _____________

License Plate (if known): ___________________

Is the respondent known to carry a weapon? o Yes o No If yes, What type: ________________________

Vehicle Information

Please provide any additional information that may assist law enforcement in locating the RespondentAdditional Information

COUNTY OF SERVICE

o Hernando o Hillsborough o Pasco o Pinellas o Polk o Other: ____________________



Instructions for Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit (11/15)

INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW FORM 12.902(d)

UNIFORM CHILD CUSTODY JURISDICTION AND ENFORCEMENT ACT (UCCJEA) AFFIDAVIT (11/15)

When should this form be used? This form should be used in any case involving custody of, visitation with, or time-sharing with any minor child(ren). This affidavit is required even if the custody of, visitation, or time-sharing with the minor child(ren) are not in dispute. This form should be typed or printed in black ink. After completing this form, you should sign the form before a notary public or deputy clerk. You should then file the original with the clerk of the circuit court in the county where the petition was filed and keep a copy for your records.

IMPORTANT INFORMATION REGARDING E-FILING

The Florida Rules of Judicial Administration now require that all petitions, pleadings, and documents be filed electronically except in certain circumstances. Self-represented litigants may file petitions or other pleadings or documents electronically; however, they are not required to do so. If you choose to file your pleadings or other documents electronically, you must do so in accordance with Florida Rule of Judicial Administration 2.525, and you must follow the procedures of the judicial circuit in which you file. The rules and procedures should be carefully read and followed.

What should I do next? A copy of this form must be mailed, e-mailed, or hand delivered to the other party in your case, if it is not served on him or her with your initial papers.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION After the initial service of process of the petition or supplemental petition by the Sheriff or certified process server, the Florida Rules of Judicial Administration now require that all documents required or permitted to be served on the other party must be served by electronic mail (e-mail) except in certain circumstances. You must strictly comply with the format requirements set forth in the Rules of Judicial Administration. If you elect to participate in electronic service, which means serving or receiving pleadings by electronic mail (e-mail), or through the Florida Courts E-Filing Portal, you must review Florida Rule of Judicial Administration 2.516. You may find this rule at www.flcourts.org through the link to the Rules of Judicial Administration provided under either Family Law Forms: Getting Started, or Rules of Court in the A-Z Topical Index.


Instructions for Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit (11/15)

SELF-REPRESENTED LITIGANTS MAY SERVE DOCUMENTS BY E-MAIL; HOWEVER, THEY ARE NOT REQUIRED TO DO SO. If a self-represented litigant elects to serve and receive documents by e-mail, the procedures must always be followed once the initial election is made. To serve and receive documents by e-mail, you must designate your e-mail addresses by using the Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family Law Form 12.915, and you must provide your e-mail address on each form on which your signature appears. Please CAREFULLY read the rules and instructions for: Certificate of Service (General), Florida Supreme Court Approved Family Law Form 12.914; Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family Law Form 12.915; and Florida Rule of Judicial Administration 2.516.

Where can I look for more information? Before proceeding, you should read General Information for Self-Represented Litigants found at the beginning of these forms. The words that are in bold underline in these instructions are defined there. For further information, see sections 61.501-61.542, Florida Statutes.

Special notes... Chapter 2008-61, Laws of Florida, effective October 1, 2008, eliminated such terms as custodial parent, noncustodial parent, primary residential parent, secondary residential parent, and visitation from Chapter 61, Florida Statutes. Instead, parents are to develop a Parenting Plan that includes, among other things, their time-sharing schedule with the minor child(ren). If the parents cannot agree, a parenting plan will be established by the Court. However, because the UCCJEA uses the terms custody and visitation, they are included in this form. If you are the petitioner in an injunction for protection against domestic violence case and you have filed a Request for Confidential Filing of Address, Florida Supreme Court Approved Family Law Form 12.980(h), you should write confidential in any space on this form that would require you to write the address where you are currently living. Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida Family Law Rules of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill out these forms also must put his or her name, address, and telephone number on the bottom of the last page of every form he or she helps you complete.

Florida Supreme Court Approved Family Law Form 12.902(d), Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit (11/15)

IN THE CIRCUIT COURT OF THE_______________________JUDICIAL CIRCUIT, IN AND FOR_______________________COUNTY, FLORIDA

Case No.:_______________________________ Division:________________________________

________________________________, Petitioner,

and ________________________________,

Respondent.

UNIFORM CHILD CUSTODY JURISDICTION AND ENFORCEMENT ACT (UCCJEA) AFFIDAVIT

I, {full legal name} ________________________________, being sworn, certify that the following statements are true: 1. The number of minor child(ren) subject to this proceeding is _________. The name, place of

birth, birth date, and sex of each child; the present address, periods of residence, and places where each child has lived within the past five (5) years; and the name, present address, and relationship to the child of each person with whom the child has lived during that time are:

THE FOLLOWING INFORMATION IS TRUE ABOUT CHILD # 1 : Child’s Full Legal Name: _________________________________________________________________ Place of Birth: _________________ Date of Birth: _________________ Sex: _______________________ Child’s Residence for the past 5 years:

Dates (From/To)

Address (including city and state) where child lived

Name and present address of person child lived with

Relationship to child

/present*

____/____

____/____


____/____

____/____

____/____

* If you are the petitioner in an injunction for protection against domestic violence case and you have filed a Request for Confidential Filing of Address, Florida Supreme Court Approved Family Law Form 12.980(h), you should write confidential in any space on this form that would require you to enter the address where you are currently living. THE FOLLOWING INFORMATION IS TRUE ABOUT CHILD # ______: Child’s Full Legal Name: _________________________________________________________________ Place of Birth: _________________ Date of Birth: _________________ Sex: _______________________ Child’s Residence for the past 5 years:

Dates (From/To)




/present*

____/____

____/____

____/____

____/____

____/____


THE FOLLOWING INFORMATION IS TRUE ABOUT CHILD # ______: Child’s Full Legal Name: _________________________________________________________________ Place of Birth: _________________ Date of Birth: _________________ Sex: _______________________ Child’s Residence for the past 5 years:

Dates (From/To)




/present*

____/____

____/____

____/____

____/____

____/____

2. Participation in custody or time-sharing proceeding(s):

[Choose only one] ____ I HAVE NOT participated as a party, witness, or in any capacity in any other litigation or custody proceeding in this or any other state, concerning custody of or time-sharing with a child subject to this proceeding. ____ I HAVE participated as a party, witness, or in any capacity in any other litigation or custody proceeding in this or another state, concerning custody of or time-sharing with a child subject to this proceeding. Explain:

a. Name of each child: _______________________________________________________ b. Type of proceeding: _______________________________________________________ c. Court and state: __________________________________________________________ d. Date of court order or judgment (if any): ______________________________________

3. Information about custody or time-sharing proceeding(s):


[Choose only one] ____ I HAVE NO INFORMATION of any custody or time-sharing proceeding pending in a court of this or any other state concerning a child subject to this proceeding. ____ I HAVE THE FOLLOWING INFORMATION concerning a custody or time-sharing 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:

e. Name of each child: _______________________________________________________ f. Type of proceeding: _______________________________________________________ g. Court and state: __________________________________________________________ h. Date of court order or judgment (if any): ______________________________________

4. Persons not a party to this proceeding:

[Choose only one] ____ I DO NOT KNOW OF ANY PERSON not a party to this proceeding who has physical custody or claims to have custody, visitation or time-sharing with respect to any child subject to this proceeding. ____ I KNOW THAT THE FOLLOWING NAMED PERSON(S) not a party to this proceeding has (have) physical custody or claim(s) to have custody, visitation, or time-sharing with respect to any child subject to this proceeding: a. Name and address of person: ______________________________________________________ _____________________________________________________________________________________ _____ has physical custody _____ claims custody rights _____ claims visitation or time-sharing Name of each child: b. Name and address of person: ______________________________________________________ _____________________________________________________________________________________ _____ has physical custody _____ claims custody rights _____ claims visitation or time-sharing Name of each child: ______________________________________________________ _____________________________________________________________________________________ c. Name and address of person: ______________________________________________________ _____________________________________________________________________________________ _____ has physical custody _____ claims custody rights _____claims visitation or time-sharing Name of each child: ______________________________________________________ _____________________________________________________________________________________ 5. Knowledge of prior child support proceedings:

[Choose only one] _____The child(ren) described in this affidavit are NOT 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): Name of each child: ____________________________________________________________________ Type of proceeding: ____________________________________________________________________ Court and address: _____________________________________________________________________ Date of court order/judgment (if any): _____________________________________________________ Amount of child support paid and by whom: ________________________________________________ 6. I acknowledge that I have a continuing duty to advise this Court of any custody, visitation or

time-sharing, child support, or guardianship proceeding (including dissolution of marriage, separate maintenance, child neglect, or dependency) concerning the child(ren) in this state or any other state about which information is obtained during this proceeding.

I certify that a copy of this document was ( ) mailed ( ) faxed and mailed ( ) e-mailed ( ) hand delivered to the person(s) listed below on {date} _____________________________________________. Other party or his/her attorney: Name: _______________________________________ Address: ______________________________________ City, State, Zip: _________________________________ Fax Number: ___________________________________ Designated E-mail Address(es):____________________ _____________________________________________


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 _____ HUSBAND _____ WIFE Printed Name: _________________________________ Address: ______________________________________ City, State, Zip: _________________________________ Telephone Number: _____________________________ Fax Number: __________________________________ Designated E-mail Address(es): ____________________

STATE OF FLORIDA COUNTY OF ____________________ Sworn to or affirmed and signed before me on ____________ by _______________________________.

_____________________________________________ NOTARY PUBLIC or DEPUTY CLERK ____________________________________________ {Print, type, or stamp commissioned name of notary or deputy clerk.}

_____ Personally known _____ Produced identification

Type of identification produced ________________________________ 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} ( ) Husband ( ) Wife This form was completed with the assistance of: {name of individual} ____________________________________________________________________, {name of business} ____________________________________________________________________, {address} ____________________________________________________________________________, {city} ______________,{state} _____,{zip code}___________,{telephone number} ________________.

Instructions to Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form) (01/15)

INSTRUCTIONS FOR FLORIDA FAMILY LAW RULES OF PROCEDURE FORM 12.902(b), FAMILY LAW FINANCIAL AFFIDAVIT (SHORT FORM) (01/15)


This form should be used when you are involved in a family law case which requires a financial affidavit and your individual gross income is UNDER $50,000 per year unless:

(1) You are filing a simplified dissolution of marriage under rule 12.105 and both parties have waived the filing of a financial affidavit;

(2) You have no minor children, no support issues, and have filed a written settlement agreement disposing of all financial issues; or

(3) The court lacks jurisdiction to determine any financial issues. This form should be typed or printed in black ink. After completing this form, you should sign the form before a notary public or deputy clerk. You should file the original with the clerk of the circuit court in the county where the petition was filed and keep a copy for your records.

What should I do next?

A copy of this form must be served on the other party in your case within 45 days of being served with the petition, if it is not served on him or her with your initial papers. Service must be in accordance with Florida Rule of Judicial Administration 2.516.

Where can I look for more information?

Before proceeding, you should read “General Information for Self-Represented Litigants” found at the beginning of these forms. The words that are in “bold underline” in these instructions are defined there. For further information, see Florida Family Law Rule of Procedure 12.285.

Special notes...

If you want to keep your address confidential because you are the victim of sexual battery, aggravated child abuse, aggravated stalking, harassment, aggravated battery, or domestic violence, do not enter the address, telephone, and fax information at the bottom of this form. Instead, file Request for Confidential Filing of Address, Florida Supreme Court Approved Family Law Form 12.980(h). The affidavit must be completed using monthly income and expense amounts. If you are paid or your bills are due on a schedule which is not monthly, you must convert those amounts. Hints are provided below for making these conversions.

Instructions to Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form) (01/15)

Hourly - If you are paid by the hour, you may convert your income to monthly as follows: Hourly amount x Hours worked per week = Weekly amount Weekly amount x 52 Weeks per year = Yearly amount Yearly amount ÷ 12 Months per year = Monthly Amount Daily - If you are paid by the day, you may convert your income to monthly as follows: Daily amount x Days worked per week = Weekly amount Weekly amount x 52 Weeks per year = Yearly amount Yearly amount ÷ 12 Months per year = Monthly Amount Weekly - If you are paid by the week, you may convert your income to monthly as follows: Weekly amount x 52 Weeks per year = Yearly amount Yearly amount ÷ 12 Months per year = Monthly Amount Bi-weekly - If you are paid every two weeks, you may convert your income to monthly as follows: Bi-weekly amount x 26 = Yearly amount Yearly amount ÷ 12 Months per year = Monthly Amount Semi-monthly - If you are paid twice per month, you may convert your income to monthly as follows: Semi-monthly amount x 2 = Monthly Amount Expenses may be converted in the same manner. Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida Family Law Rules of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill out these forms also must put his or her name, address, and telephone number on the bottom of the last page of every form he or she helps you complete.

Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form) (01/15)

IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT, IN AND FOR COUNTY, FLORIDA

Case No.: ______________________ Division: _______________________ , Petitioner, and , Respondent.

FAMILY LAW FINANCIAL AFFIDAVIT (SHORT FORM) (Under $50,000 Individual Gross Annual Income)

I, {full legal name} , being sworn, certify that the following information is true:

My Occupation: Employed by: ___________________________

Business Address: ________________________________________________________________

Pay rate: $ ( ) every week ( ) every other week ( ) twice a month ( ) monthly ( ) other: ____________

___ Check here if unemployed and explain on a separate sheet your efforts to find employment.

SECTION I. PRESENT MONTHLY GROSS INCOME: All amounts must be MONTHLY. See the instructions with this form to figure out money amounts for anything that is NOT paid monthly. Attach more paper, if needed. Items included under “other” should be listed separately with separate dollar amounts.

1. $______ Monthly gross salary or wages

2. ______ Monthly bonuses, commissions, allowances, overtime, tips, and similar payments

3. _______Monthly business income from sources such as self-employment, partnerships, close corporations, and/or independent contracts (gross receipts minus ordinary and necessary expenses required to produce income) (Attach sheet itemizing such income and expenses.)

4. _______Monthly disability benefits/SSI

5. _______Monthly Workers’ Compensation

6. _______Monthly Unemployment Compensation

7. _______Monthly pension, retirement, or annuity payments

8. _______Monthly Social Security benefits

9. ______ Monthly alimony actually received (Add 9a and 9b)

9a. From this case: $ _______

9b. From other case(s): _______

10. _______ Monthly interest and dividends

11. _______Monthly rental income (gross receipts minus ordinary and necessary expenses

Florida Family Law Rules of Procedure Form 12.902(b), Family Law Financial Affidavit (Short Form)(01/15)

required to produce income) (Attach sheet itemizing such income and expense items.)

12. _______ Monthly income from royalties, trusts, or estates

13. _______ Monthly reimbursed expenses and in-kind payments to the extent that they reduce personal living expenses

14. _______ Monthly gains derived from dealing in property (not including nonrecurring gains)

15. _______ Any other income of a recurring nature (list source) _________________________

16. __________________________________________________________________________

17. $ _______ TOTAL PRESENT MONTHLY GROSS INCOME (Add lines 1–16)

PRESENT MONTHLY DEDUCTIONS:

18. $______Monthly federal, state, and local income tax (corrected for filing status and allowable dependents and income tax liabilities)

a. Filing Status ____________

b. Number of dependents claimed _______

19. _______ Monthly FICA or self-employment taxes

20. _______ Monthly Medicare payments

21. _______ Monthly mandatory union dues

22. _______ Monthly mandatory retirement payments

23. _______ Monthly health insurance payments (including dental insurance), excluding portion paid for any minor children of this relationship

24. _______ Monthly court-ordered child support actually paid for children from another relationship

25. _______Monthly court-ordered alimony actually paid (Add 25a and 25b)

25a. from this case: $ _______

25b. from other case(s):$ _______

26. $_______ TOTAL DEDUCTIONS ALLOWABLE UNDER SECTION 61.30, FLORIDA STATUTES

(Add lines 18 through 25).

27. $_______ PRESENT NET MONTHLY INCOME (Subtract line 26 from line 17)


SECTION II. AVERAGE MONTHLY EXPENSES Proposed/Estimated Expenses. If this is a dissolution of marriage case and your expenses as listed below do not reflect what you actually pay currently, you should write “estimate” next to each amount that is estimated. A. HOUSEHOLD: Mortgage or rent $ _______ Property taxes $_______ Utilities $_______ Telephone $ _______ Food $ _______ Meals outside home $_______ Maintenance/Repairs $ _______ Other: __________ $_______ B. AUTOMOBILE Gasoline $ _______ Repairs $_______ Insurance $_______ C. CHILD(REN)’S EXPENSES Day care $ _______ Lunch money $_______ Clothing $ _______ Grooming $_______ Gifts for holidays $ _______ Medical/Dental (uninsured) $ _______ Other: ______________ $ _______ D. INSURANCE Medical/Dental (if not listed on lines 23 or 45) $ _______ Child(ren)’s medical/dental $ _______ Life $ _______ Other: $ _______

E. OTHER EXPENSES NOT LISTED ABOVE Clothing $ _______ Medical/Dental (uninsured) $_______ Grooming $ _______ Entertainment $_______ Gifts $_______ Religious organizations $_______ Miscellaneous $_______ Other: ______________ $ _______ ____________________ $_______ ____________________ $_______ ____________________ $_______ ____________________ $_______ ____________________ $_______ F. PAYMENTS TO CREDITORS CREDITOR: MONTHLY PAYMENT ____________________ $_______ ____________________ $_______ ____________________ $_______ ____________________ $_______ ____________________ $_______ ____________________ $_______ ____________________ $_______ ____________________ $_______ ____________________ $_______ ____________________ $_______ ____________________ $_______


28. $_______ TOTAL MONTHLY EXPENSES (add ALL monthly amounts in A through F above)

SUMMARY

29. $_______ TOTAL PRESENT MONTHLY NET INCOME (from line 27 of SECTION I. INCOME)

30. $_______ TOTAL MONTHLY EXPENSES (from line 28 above)

31. $_______ SURPLUS (If line 29 is more than line 30, subtract line 30 from line 29. This is the amount of your surplus. Enter that amount here.)

32. ($_______) (DEFICIT) (If line 30 is more than line 29, subtract line 29 from line 30. This is the amount of your deficit. Enter that amount here.)

SECTION III. ASSETS AND LIABILITIES Use the nonmarital column only if this is a petition for dissolution of marriage and you believe an item is “nonmarital,” meaning it belongs to only one of you and should not be divided. You should indicate to whom you believe the item(s) or debt belongs. (Typically, you will only use this column if property/debt was owned/owed by one spouse before the marriage. See the “General Information for Self-Represented Litigants” found at the beginning of these forms and section 61.075(1), Florida Statutes, for definitions of “marital” and “nonmarital” assets and liabilities.) A. ASSETS: DESCRIPTION OF ITEM(S). List a description of each separate item owned by you (and/or your spouse, if this is a petition for dissolution of marriage). LIST ONLY LAST 4 DIGITS OF ACCOUNT NUMBERS. Check the line next to any asset(s) which you are requesting the judge award to you.

Current Fair

Market Value

Nonmarital

(check correct column)

husband

wife

Cash (on hand)

$

Cash (in banks or credit unions)

Stocks, Bonds, Notes

Real estate: (Home)

(Other)

Automobiles

Other personal property

Retirement plans (Profit Sharing, Pension, IRA, 401(k)s, etc.)

Other

____Check here if additional pages are attached.

Total Assets (add next column) $


B. LIABILITIES: DESCRIPTION OF ITEM(S). List a description of each separate debt owed by you (and/or your spouse, if this is a petition for dissolution of marriage). LIST ONLY LAST 4 DIGITS OF ACCOUNT NUMBERS. Check the line next to any debt(s) for which you believe you should be responsible.

Current Amount

Owed

Nonmarital


husband wife

Mortgages on real estate: First mortgage on home

$

Second mortgage on home

Other mortgages

Auto loans

Charge/credit card accounts

Other

____Check here if additional pages are attached.

Total Debts (add next column)

$

C. CONTINGENT ASSETS AND LIABILITIES: INSTRUCTIONS: If you have any POSSIBLE assets (income potential, accrued vacation or sick leave, bonus, inheritance, etc.) or POSSIBLE liabilities (possible lawsuits, future unpaid taxes, contingent tax liabilities, debts assumed by another), you must list them here.

Contingent Assets

Check the line next to any contingent asset(s) which you are requesting the judge award to you.

Possible Value

Nonmarital


husband

wife

$

Total Contingent Assets

$

Contingent Liabilities

Check the line next to any contingent debt(s) for which you believe you should be responsible.

Possible Amount

Owed

Nonmarital


husband

wife

$

Total Contingent Liabilities

$


SECTION IV. CHILD SUPPORT GUIDELINES WORKSHEET (Florida Family Law Rules of Procedure Form 12.902(e), Child Support Guidelines Worksheet, MUST be filed with the court at or prior to a hearing to establish or modify child support. This requirement cannot be waived by the parties.) [Check one only] ____ A Child Support Guidelines Worksheet IS or WILL BE filed in this case. This case involves the establishment or modification of child support. ____ A Child Support Guidelines Worksheet IS NOT being filed in this case. The establishment or modification of child support is not an issue in this case. I certify that a copy of this document was [check all used]: ( ) e-mailed ( ) mailed ( ) faxed ( ) hand delivered to the person(s) listed below on {date} ________________________________. Other party or his/her attorney: Name: _____________________________ Address: ____________________________ City, State, Zip: _______________________ Fax Number: _________________________ E-mail Address(es): _____________________ I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this affidavit and that the punishment for knowingly making a false statement includes fines and/or imprisonment. Dated: Signature of Party Printed Name: ________________________________ Address: ___________________________________ City, State, Zip: ______________________________ Fax Number: ________________________________ E-mail Address(es): ____________________________ STATE OF FLORIDA COUNTY OF Sworn to or affirmed and signed before me on by . ________________________________ NOTARY PUBLIC or DEPUTY CLERK ________________________________ [Print, type, or stamp commissioned name of notary or deputy clerk.] ____ Personally known ____ Produced identification Type of identification produced


IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW: [fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent This form was completed with the assistance of: {name of individual} , {name of business} ___________________________________________________________________, {address} ________________________________, {city} ________,{state} ________ {telephone number} .

Instructions for Florida Supreme Court Approved Family Law Form 12.902(j), Notice of Social Security Number (11/15)

INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW FORM 12.902(j),

NOTICE OF SOCIAL SECURITY NUMBER (11/15)


This form must be completed and filed by each party in all paternity, child support, and dissolution of marriage cases, regardless of whether the case involves a minor child(ren) and/or property. This form should be typed or printed in black ink. After completing this form, you should file the original with the clerk of the circuit court in the county where your case was filed and keep a copy for your records.


What should I do next? A copy of this form must be mailed, e-mailed, or hand delivered to the other party in your case, if it is not served on him or her with your initial papers.

IMPORTANT INFORMATION REGARDING E-SERVICE ELECTION After the initial service of process of the petition or supplemental petition by the Sheriff or certified process server, the Florida Rules of Judicial Administration now require that all documents required or permitted to be served on the other party must be served by electronic mail (e-mail) except in certain circumstances. You must strictly comply with the format requirements set forth in the Rules of Judicial Administration. If you elect to participate in electronic service, which means serving or receiving pleadings by electronic mail (e-mail), or through the Florida Courts E-Filing Portal, you must review Florida Rule of Judicial Administration 2.516. You may find this rule at www.flcourts.org through the link to the Rules of Judicial Administration provided under either Family Law Forms: Getting Started, or Rules of Court in the A-Z Topical Index. SELF-REPRESENTED LITIGANTS MAY SERVE DOCUMENTS BY E-MAIL; HOWEVER, THEY ARE NOT REQUIRED TO DO SO. If a self-represented litigant elects to serve and receive documents by e-mail, the


Instructions for Florida Supreme Court Approved Family Law Form 12.902(j), Notice of Social Security Number (11/15)

procedures must always be followed once the initial election is made. To serve and receive documents by e-mail, you must designate your e-mail addresses by using the Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family Law Form 12.915, and you must provide your e-mail address on each form on which your signature appears. Please CAREFULLY read the rules and instructions for: Certificate of Service (General), Florida Supreme Court Approved Family Law Form 12.914; Designation of Current Mailing and E-mail Address, Florida Supreme Court Approved Family Law Form 12.915; and Florida Rule of Judicial Administration 2.516.


Before proceeding, you should read General Information for Self-Represented Litigants found at the beginning of these forms. The words that are in “bold underline” in these instructions are defined there. For further information, see chapter 61, Florida Statutes.

Special notes...

If this is a domestic violence case and you want to keep your address confidential for safety reasons, do not enter the address, telephone, fax, or e-mail information at the bottom of this form. Instead, file a Request for Confidential Filing of Address, Florida Supreme Court Approved Family Law Form 12.980(i). Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida Family Law Rules of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill out these forms also must put his or her name, address, and telephone number on the bottom of the last page of every form he or she helps you complete.

Florida Supreme Court Approved Family Law Form 12.902(j), Notice of Social Security Number (11/15)


Case No.: Division:

,

Petitioner,

and

,

Respondent.

NOTICE OF SOCIAL SECURITY NUMBER

I, {full legal name} ___________________________________________________________, certify that my social security number is ___________________________, as required by the applicable section of the Florida Statutes. My date of birth is ______________________________. [Choose one only] __ 1. This notice is being filed in a dissolution of marriage case in which the parties have no minor

children in common. __ 2. This notice is being filed in a paternity or child support case, or in a dissolution of marriage

in which the parties have minor children in common. The minor child(ren)'s name(s), date(s) of birth, and social security number(s) is/are:

Name Birth date Social Security Number ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ {Attach additional pages if necessary.} Disclosure of social security numbers shall be limited to the purpose of administration of the Title IV-D program for child support enforcement.

Florida Supreme Court Approved Family Law Form 12.902(j), Notice of Social Security Number (11/15)

I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this notice and that the punishment for knowingly making a false statement includes fines and/or imprisonment.

Dated: ___________________ _____________________________________________

Signature Printed Name:

Address: City, State, Zip: Telephone Number: Fax Number:

Designated E-mail Address(es):____________________ _____________________________________________

STATE OF FLORIDA COUNTY OF ________

Sworn to or affirmed and signed before me on by .

__________________ NOTARY PUBLIC or DEPUTY CLERK ___________________ [Print, type, or stamp commissioned name of notary or clerk]

Personally known Produced identification Type of identification produced IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW: [fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent This form was completed with the assistance of: {name of individual}___________________________________________________________________, {name of business} ____________________________________________________________________, {address} _______________________________________________________________________, {city} ______________, {state} _____,{zip code}_____________, {telephone number} _____________.

Instructions for Florida Family Law Rules of Procedure Form 12.928, Cover Sheet for Family Court Cases (11/13)

INSTRUCTIONS FOR FLORIDA FAMILY LAW RULES OF PROCEDURE FORM 12.928, COVER SHEET FOR FAMILY COURT CASES (11/13)


The Cover Sheet for Family Court Cases and the information contained in it neither replace nor supplement the filing and service of pleadings or other documents as required by law. This form shall be filed by the petitioner/party opening or reopening a case for the use of the clerk of the circuit court for the purpose of reporting judicial workload data pursuant to Florida Statutes section 25.075. This form should be typed or printed in black ink. The petitioner must file this cover sheet with the first pleading or motion filed to open or reopen a case in all domestic and juvenile cases.


Follow these instructions for completing the form: I. Case Style. Enter the name of the court, the appropriate case number assigned at the time

of filing of the original petition, the name of the judge assigned (if applicable), and the name (last, first, middle initial) of the petitioner(s) and respondent(s).

II. Type of Action /Proceeding. Place a check beside the proceeding you are initiating. If you are simultaneously filing more than one type of proceeding against the same opposing party, such as a modification and an enforcement proceeding, complete a separate cover sheet for each action being filed.

(A) Initial Action/Petition

(B) Reopening Case. If you check “Reopening Case,” indicate whether you are filing a modification or supplemental petition or an action for enforcement by placing a check beside the appropriate action/petition.

1. Modification/Supplemental Petition

2. Motion for Civil Contempt/ Enforcement

3. Other – All reopening actions not involving modification/supplemental petitions or petition enforcement.

III. Type of Case. Place a check beside the appropriate case. If the case fits more than one

category, select the most definitive. Definitions of the categories are provided below.

(A) Simplified Dissolution of Marriage‐ petitions for the termination of marriage pursuant to Florida Family Law Rule of Procedure 12.105.

(B) Dissolution of Marriage ‐ petitions for the termination of marriage pursuant to Chapter 61, Florida Statutes, other than simplified dissolution.

(C) Domestic Violence ‐ all matters relating to injunctions for protection against domestic violence pursuant to section 741.30, Florida Statutes.


(D) Dating Violence ‐ all matters relating to injunctions for protection against dating violence pursuant to section 784.046, Florida Statutes.

(E) Repeat Violence ‐ all matters relating to injunctions for protection against repeat violence pursuant to section 784.046, Florida Statutes.

(F) Sexual Violence ‐ all matters relating to injunctions for protection against sexual violence pursuant to section 784.046, Florida Statutes.

(G) Stalking-all matters relating to injunctions for protection against stalking pursuant to section 784.0485, Florida Statutes

(H) Support ‐ IV‐D ‐ all matters relating to child or spousal support in which an application for assistance has been filed with the Department of Revenue, Child Support Enforcement under Title IV‐D, Social Security Act, except for such matters relating to dissolution of marriage petitions (sections 409.2564, 409.2571, and 409.2597, Florida Statutes), paternity, or UIFSA.

(I) Support‐Non IV‐D ‐ all matters relating to child or spousal support in which an application for assistance has not been filed under Title IV‐D, Social Security Act.

(J) UIFSA‐ IV‐D ‐ all matters relating to Chapter 88, Florida Statutes, in which an application for assistance has been filed under Title IV‐D, Social Security Act.

(K) UIFSA ‐ Non IV‐D ‐ all matters relating to Chapter 88, Florida Statutes, in which an application for assistance has not been filed under Title IV‐D, Social Security Act.

(L) Other Family Court ‐ all matters involving time-sharing and/or parenting plans relating to minor child(ren), support unconnected with dissolution of marriage, annulment, delayed birth certificates pursuant to Florida Statutes section 382.0195, expedited affirmation of parental status pursuant to Florida Statutes section 742.16, termination of parental rights proceedings pursuant to Florida Statutes section 63.087, declaratory judgment actions related to premarital, marital, post-marital agreements, or other matters not included in the categories above.

(M) Adoption Arising Out Of Chapter 63 ‐ all matters relating to adoption pursuant to Chapter 63, Florida Statutes, excluding any matters arising out of Chapter 39, Florida Statutes.

(N) Name Change ‐ all matters relating to name change, pursuant to section 68.07, Florida Statutes.

(O) Paternity/Disestablishment of Paternity – all matters relating to paternity pursuant to Chapter 742, Florida Statutes.

(P) Juvenile Delinquency ‐ all matters relating to juvenile delinquency pursuant to Chapter 985, Florida Statutes.

(Q) Petition for Dependency ‐ all matters relating to petitions for dependency.

(R) Shelter Petition – all matters relating to shelter petitions pursuant to Chapter 39, Florida Statutes.

(S) Termination of Parental Rights Arising Out Of Chapter 39 – all matters relating to termination of parental rights pursuant to Chapter 39, Florida Statutes.

(T) Adoption Arising Out Of Chapter 39 – all matters relating to adoption pursuant to Chapter 39, Florida Statutes.

(U) CINS/FINS – all matters relating to children in need of services (and families in need of services) pursuant to Chapter 984, Florida Statutes.


ATTORNEY OR PARTY SIGNATURE. Sign the Cover Sheet for Family Court Cases. Print legibly the name of the person signing the Cover Sheet for Family Court Cases. Attorneys must include a Florida Bar number. Insert the date the Cover Sheet for Family Court Cases is signed. Signature is a certification that filer has provided accurate information on the Cover Sheet for Family Court Cases. Nonlawyer Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out these forms, that person must give you a copy of Disclosure from Nonlawyer, Florida Family Law Rules of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill out these forms also must put his or her name, address, and telephone number on the bottom of the last page of every form he or she helps you complete.


Before proceeding, you should read “General Information for Self-Represented Litigants” found at the beginning of these forms. For further information, see Rule 12.100, Florida Family Law Rules of Procedure.

Florida Family Law Rules of Procedure Form 12.928, Cover Sheet for Family Court Cases (11/13)

COVER SHEET FOR FAMILY COURT CASES I. Case Style

IN THE CIRCUIT COURT OF THE ______ JUDICIAL CIRCUIT, IN AND FOR __________________ COUNTY, FLORIDA

Case No.: ________________ Judge: __________________ _____________________________ Petitioner and _____________________________ Respondent II. Type of Action/Proceeding. Place a check beside the proceeding you are initiating. If you are

simultaneously filing more than one type of proceeding against the same opposing party, such as a modification and an enforcement proceeding, complete a separate cover sheet for each action being filed. If you are reopening a case, choose one of the three options below it.

(A) ____ Initial Action/Petition (B) ____ Reopening Case

1. ____ Modification/Supplemental Petition 2. ____ Motion for Civil Contempt/Enforcement 3. ____ Other

III. Type of Case. If the case fits more than one type of case, select the most definitive.

(A) ____ Simplified Dissolution of Marriage (B) ____ Dissolution of Marriage (C) ____ Domestic Violence (D) ____ Dating Violence (E) ____ Repeat Violence (F) ____ Sexual Violence (G) ____ Stalking (H) ____ Support IV‐D (Department of Revenue, Child Support Enforcement) (I) ____ Support Non‐IV‐D (not Department of Revenue, Child Support Enforcement) (J) ____ UIFSA IV‐D (Department of Revenue, Child Support Enforcement) (K) ____ UIFSA Non‐IV‐D (not Department of Revenue, Child Support Enforcement) (L) ____ Other Family Court (M) ____ Adoption Arising Out Of Chapter 63 (N) ____ Name Change

Florida Family Law Rules of Procedure Form 12.928, Cover Sheet for Family Court Cases (11/13)

(O) ____ Paternity/Disestablishment of Paternity (P) ____ Juvenile Delinquency (Q) ____ Petition for Dependency (R) ____ Shelter Petition (S) ____ Termination of Parental Rights Arising Out Of Chapter 39 (T) ____ Adoption Arising Out Of Chapter 39 (U) ____ CINS/FINS

IV. Rule of Judicial Administration 2.545(d) requires that a Notice of Related Cases Form, Family

Law Form 12.900(h), be filed with the initial pleading/petition by the filing attorney or self-represented litigant in order to notify the court of related cases. Is Form 12.900(h) being filed with this Cover Sheet for Family Court Cases and initial pleading/petition? ____ No, to the best of my knowledge, no related cases exist. ____ Yes, all related cases are listed on Family Law Form 12.900(h).

ATTORNEY OR PARTY SIGNATURE

I CERTIFY that the information I have provided in this cover sheet is accurate to the best of my knowledge and belief.

Signature________________________________________ FL Bar No.: _____________________ Attorney or party (Bar number,if attorney) ________________________________________ __________________________ (Type or print name) (E-mail Address(es)) ____________________________ Date IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW: [fill in all blanks] This form was prepared for the: {choose only one} ( ) Petitioner ( ) Respondent This form was completed with the assistance of: {name of individual}____________________________________________________________, {name of business} ______________________________________________________________, {address}______________________________________________________________________, {city}_________________________, {state}______ , {telephone number }__________________.

COURT INTAKE FORM 1 R02/10/09

COURT INTAKE FORM This information will be kept in a separate file from the cases that have been filed. To help us comply with Federal State Reporting requirements and to provide you the petitioner with community services options, please answer the following questions: Date: Name: Sex: Phone # Address: Zip Code Do you elect to keep your address confidential? Yes No Date of Birth: Race: Hispanic Black Asian White American Indian Other Referral Source: [circle one] Law Enforcement Victim Attorney Family/Friend State Attorney Human Service Agency Self Children’s Names: SSN # Date of Birth: Child’s Mother Child’s Father Name: Name:

1. Are you married? Yes No 2. Have you lived at a shelter? Yes No 3. Did you complete High School or receive a GED? Yes No 4. Do you or another adult in your home need assistance reading? Yes No 5. Do you receive AFDC? Yes No 6. Are you employed outside the home? Yes No 7. Do you have a restraining order now or have you had one in the past? Yes No 8. Do you receive disability benefits? Yes No 9. Is the incident alcohol or drug related? Yes No 10. Have you or anyone in your household ever been arrested for Domestic Violence? Yes No 11. Does anyone in your household or family hurt, harass, intimidate or threaten any any other member of the household or family? Yes No 12. Are you currently pregnant? Yes No 13. Do you need a place to stay temporarily until stable housing is found? Yes No 14. Please circle the items you have immediate needs for: Housing Food Child Care Transportation Counseling Parenting Classes Legal Assistance 15. May we have an outside agency or agencies contact you to assist you with these needs and services? Yes No 16. May we have someone from the domestic violence center contact you? Yes No 17. Is it safe to contact you at the above listed number? Yes No If no, how can we safely contact you? Signature of Party: Please list any other cases that are currently open or pending on the back of this form. Include any civil, probate, dependency, delinquency or criminal cases and the county they are in.

Instructions for Florida Family Law Rules of Procedure Form 12.900(h), Notice of Related Cases (11/13)

INSTRUCTIONS FOR FLORIDA FAMILY LAW RULES OF PROCEDURE FORM 12.900(h), NOTICE OF RELATED CASES (11/13)


Florida Rule of Judicial Administration 2.545(d) requires the petitioner in a family law case to file with the court a notice of related cases, if any. Your circuit may also require this form to be filed even if there are no related cases. A case is considered related if

it involves the same parties, children, or issues and is pending when the family law case is filed; or

it affects the court’s jurisdiction to proceed; or

an order in the related case may conflict with an order on the same issues in the new case; or

an order in the new case may conflict with an order in the earlier case. This form is used to provide the required notice to the court. This form should be typed or printed in black ink. It must be filed with the clerk of the circuit court with the initial pleading in the family law case.


A copy of the form must be served on the presiding judges, either the chief judge or the family law administrative judge, and all parties in the related cases. You should also keep a copy for your records. Service must be in accordance with Florida Rule of Judicial Administration 2.516.


Before proceeding, you should read “General Information for Self-Represented Litigants” found at the beginning of these forms. The words that are in ”bold underline” in these instructions are defined there. For further information, see Florida Rule of Judicial Administration 2.545(d).

Special notes . . .

Remember, a person who is NOT an attorney is called a nonlawyer. If a nonlawyer helps you fill out these forms, that person must give you a copy of a Disclosure from Nonlawyer, Florida

Instructions for Florida Family Law Rules of Procedure Form 12.900(h), Notice of Related Cases (11/13)

Family Law Rules of Procedure Form 12.900(a), before he or she helps you. A nonlawyer helping you fill out these forms must also put his or her name, address, and telephone number on the bottom of the last page of every form he or she helps you complete.

Florida Family Law Rules of Procedure Form 12.900(h), Notice of Related Cases (11/13)


Case No.: Division:

_____________________________,

Petitioner, and

_____________________________,

Respondent.

NOTICE OF RELATED CASES

1. Petitioner submits this Notice of Related Cases as required by Florida Rule of Judicial Administration 2.545(d). A related case may be an open or closed civil, criminal, guardianship, domestic violence, juvenile delinquency, juvenile dependency, or domestic relations case. A case is “related” to this family law case if it involves any of the same parties, children, or issues and it is pending at the time the party files a family case; if it affects the court’s jurisdiction to proceed; if an order in the related case may conflict with an order on the same issues in the new case; or if an order in the new case may conflict with an order in the earlier litigation. [check one only] ___ There are no related cases. ___ The following are the related cases (add additional pages if necessary):

Related Case No. 1 Case Name(s): _____________________________________________________________________ Petitioner ________________________________________________________________________ Respondent _______________________________________________________________________ Case No.: _________________________________ Division: ________________________________ Type of Proceeding: [check all that apply] ____ Dissolution of Marriage ____ Paternity ____ Custody ____ Adoption ____ Child Support ____ Modification/Enforcement/Contempt Proceedings ____ Juvenile Dependency ____ Juvenile Delinquency ____ Termination of Parental Rights ____ Criminal ____ Domestic/Sexual/Dating/Repeat ____ Mental Health Violence or Stalking Injunctions ____ Other {specify}___________________________


State where case was decided or is pending: ____ Florida ____ Other: {specify} _________________

Name of Court where case was decided or is pending (for example, Fifth Circuit Court, Marion County, Florida): __________________________________________________________________ Title of last Court Order/Judgment (if any): ______________________________________________ Date of Court Order/Judgment (if any): _________________________________________________ Relationship of cases check all that apply]: ____ pending case involves same parties, children, or issues; ____ may affect court’s jurisdiction; ____ order in related case may conflict with an order in this case; ____ order in this case may conflict with previous order in related case. Statement as to the relationship of the cases: ____________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Related Case No. 2 Case Name(s): _____________________________________________________________________ Petitioner ________________________________________________________________________ Respondent _______________________________________________________________________ Case No.: _________________________________ Division: ________________________________ Type of Proceeding: [check all that apply] ____ Dissolution of Marriage ____ Paternity ____ Custody ____ Adoption ____ Child Support ____ Modification/Enforcement/Contempt Proceedings ____ Juvenile Dependency ____ Juvenile Delinquency ____ Termination of Parental Rights ____ Criminal ____ Domestic/Sexual/Dating/Repeat ____ Mental Health Violence or Stalking Injunctions ____Other {specify}__________________________ State where case was decided or is pending: ____ Florida ____ Other: {specify} _________________

Name of Court where case was decided or is pending (for example, Fifth Circuit Court, Marion County, Florida): __________________________________________________________________ Title of last Court Order/Judgment (if any): ______________________________________________ Date of Court Order/Judgment (if any): _________________________________________________ Relationship of cases check all that apply]: ____ pending case involves same parties, children, or issues;


____ may affect court’s jurisdiction; ____ order in related case may conflict with an order in this case; ____ order in this case may conflict with previous order in related case. Statement as to the relationship of the cases: ____________________________________________ __________________________________________________________________________________ __________________________________________________________________________________

Related Case No. 3 Case Name(s): _____________________________________________________________________ Petitioner ________________________________________________________________________ Respondent _______________________________________________________________________ Case No.: _________________________________ Division: ________________________________ Type of Proceeding: [check all that apply] ____ Dissolution of Marriage ____ Paternity ____ Custody ____ Adoption ____ Child Support ____ Modification/Enforcement/Contempt Proceedings ____ Juvenile Dependency ____ Juvenile Delinquency ____ Termination of Parental Rights ____ Criminal ____ Domestic/Sexual/Dating/Repeat ____ Mental Health Violence or Stalking Injunctions ____Other {specify} __________________________ State where case was decided or is pending: ____ Florida ____ Other: {specify} _________________

Name of Court where case was decided or is pending (for example, Fifth Circuit Court, Marion County, Florida): __________________________________________________________________ Title of last Court Order/Judgment (if any): ______________________________________________ Date of Court Order/Judgment (if any): _________________________________________________ Relationship of cases check all that apply]: ____ pending case involves same parties, children, or issues; ____ may affect court’s jurisdiction; ____ order in related case may conflict with an order in this case; ____ order in this case may conflict with previous order in related case. Statement as to the relationship of the cases: ____________________________________________ __________________________________________________________________________________ __________________________________________________________________________________

2. [check one only] ____ I do not request coordination of litigation in any of the cases listed above.


____ I do request coordination of the following cases: _____________________________________ ______________________________________________________________________________ ______________________________________________________________________________

3. [check all that apply]

____ Assignment to one judge ____ Coordination of existing cases will conserve judicial resources and promote an efficient determination of these cases because:_______________________________________________________________________.

4. The Petitioner acknowledges a continuing duty to inform the court of any cases in this or any other

state that could affect the current proceeding.

Dated: _________________ ________________________________________ Petitioner’s Signature

Printed Name: ______________________________ Address: ________________________________ City, State, Zip: ___________________________ Telephone Number: _______________________ Fax Number: ____________________________ E-mail Address(es):________________________

CERTIFICATE OF SERVICE

I CERTIFY that I delivered a copy of this Notice of Related Cases to the _____________________ County Sheriff’s Department or a certified process server for service on the Respondent, and [check all used] ( ) e-mailed ( ) mailed ( ) hand delivered, a copy to {name}________________________, who is the [check all that apply] ( ) judge assigned to new case, ( ) chief judge or family law administrative judge, ( ) {name}__________________________________ a party to the related case, ( ) {name} ____________________________, a party to the related case on {date} _________________________. ____________________________________ Signature of Petitioner/Attorney for Petitioner Printed Name:________________________ Address:____________________________ City, State, Zip:________________________ Telephone Number:____________________ Fax Number:__________________________ E-mail Address(es):______________________ Florida Bar Number:_____________________


IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW: [fill in all blanks] This form was prepared for the {choose only one}: ( ) Petitioner ( ) Respondent. This form was completed with the assistance of: {name of individual} ______________________________________________________________, {name of business}_______________________________________________________________, {address}______________________________________________________________________, {city} _______________________{state} __________, {telephone number} ___________________.

Instructions for Florida Supreme Court Approved Family Law Form 12.980(h), Request for Confidential Filing of Address (03/15)

INSTRUCTIONS FOR FLORIDA SUPREME COURT APPROVED FAMILY LAW FORM 12.980(h)

REQUEST FOR CONFIDENTIAL FILING OF ADDRESS (03/15)


If you fear that disclosing your address would put you in danger because you are the victim of sexual battery, aggravated child abuse, stalking, aggravated stalking, harassment, aggravated battery, or domestic violence, you should complete this form and file it with the clerk of the circuit court. This form should be typed or printed in black ink. After completing this form, you should file the original with the clerk of the circuit court in the county where your petition was filed and keep a copy for your records.


Florida Supreme Court Approved Family Law Form 12.980(h), Request for Confidential Filing of Address (03/15)


Case No.: Division:

___________________, Petitioner,

and

___________________,

Respondent.

REQUEST FOR CONFIDENTIAL FILING OF ADDRESS I, {full legal name} , request that the Court maintain and hold as confidential, the following address:

Address City State Zip Telephone (area code and number)

This request is being made for the purpose of keeping the location of my residence unknown for safety reasons pursuant to section 119.071(2)(j)1, section 784.0485(3)(b)1, Florida Statutes, or other statutory provision providing for the separate confidential filing for safety reasons. Dated: __________________________________________

Signature

CLERK’S CERTIFICATE AS TO REQUEST FOR CONFIDENTIAL FILING OF ADDRESS

I, , as Clerk of the Circuit Court, do hereby certify that I received and filed the above and will keep the above address confidential, subsequent to further order of the Court relative to such confidentiality.

CLERK OF THE CIRCUIT COURT

(SEAL) By: {Deputy Clerk}

INSTRUCTIONS FOR THE SUPPLEMENTAL INFORMATION REGARDING PARTIES FORM

The Supplemental Information Regarding Parties form will aid the Court and the Clerk of the Circuit Court in identifying related cases. This will help ensure that your related cases are heard before the same judge at the same time and reduce the number of times you have to appear in court. When should this form be filed? The Supplemental Information Regarding Parties form only needs to be completed and filed in civil domestic violence cases, dissolution cases, paternity cases, or child support actions. Who should complete and file the form? The Supplemental Information Regarding Parties form must be completed and filed by the Petitioner with the case-initiating documents. The Respondent may choose to complete and file the form at a later date. How should the form be completed? The person completing the Supplemental Information Regarding Parties form should answer the questions relating to them thoroughly and accurately. The person should also make a good faith effort to complete the portion of the form relating to the opposing party. What should I do next? The Supplemental Information Regarding Parties form must be served on the opposing party. Service must be in accordance with Florida Rule of Judicial Administration 2.516, except that the Petitioner may choose to serve the form along with the case-initiating documents.

IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL CIRCUIT, IN AND FOR PASCO/PINELLAS COUNTY, FLORIDA

_____________________________ Petitioner, Case No.: ___________________

and Section: ___________________

______________________________ Respondent. _______________________________/

SUPPLEMENTAL INFORMATION REGARDING PARTIES

The information provided in this form will assist the court and the Clerk of the Circuit Court in identification of related cases pursuant to Florida Rule of Judicial Administration 2.545.

1. Petitioner’s Information: a. Full Legal Name: _____________________________________________ b. Previous Names: _____________________________________________

(Maiden names, previous married or legal names, aliases (AKA’s)) c. Date of Birth: __________________ PID/SPN: d. Information on Children:

i. __Petitioner does not have any minor children.

ii. __Petitioner has a minor child(ren) in common with Respondent. (If you have checked this line, please complete page 2.)

iii. __Petitioner has a minor child(ren) NOT in common with Respondent. (If you have checked this line, please complete page 3.)

2. Respondent’s Information: a. Full Legal Name: _____________________________________________ b. Previous Names: _____________________________________________

(Maiden names, previous married or legal names, aliases (AKA’s)) c. Date of Birth: __________________ PID/SPN: d. Information on Children:

i. __Respondent does not have any minor children.

ii. __Respondent has a minor child(ren) in common with Petitioner. (If you have checked this line, please complete page 2.)

iii. __Respondent has a minor child(ren) NOT in common with Petitioner. (If you have checked this line, please complete page 3.)

Case Number: Section:

Sixth Circuit Administrative Order 2016-030 - Attachment A Page 2 of 4

3. Minor Child(ren) In Common: The number of minor children In Common is _____.

Information about child #1: Date of Birth: _________________ Sex: __________ Child’s Full Legal Name: _______________________________________________ Has the child’s name ever been changed? ___ Yes ___ No

If yes, list the child’s name before it was changed: _________________________ Information about child #2: Date of Birth: _________________ Sex: __________ Child’s Full Legal Name: _______________________________________________ Has the child’s name ever been changed? ___ Yes ___ No





If yes, list the child’s name before it was changed: _________________________

If additional space is needed, please use another sheet of paper and attach it to this form.



4. Minor Child(ren) NOT In Common: The number of minor children NOT In

Common is _____. Information about child #1: Date of Birth: _________________ Sex: __________ Child’s Full Legal Name: _______________________________________________ Has the child’s name ever been changed? ___ Yes ___ No

If yes, list the child’s name before it was changed: _________________________ This is the child of (please check one): Petitioner Respondent Information about child #2: Date of Birth: _________________ Sex: __________ Child’s Full Legal Name: _______________________________________________ Has the child’s name ever been changed? ___ Yes ___ No





If yes, list the child’s name before it was changed: _________________________ This is the child of (please check one): Petitioner Respondent

If additional space is needed, please use another sheet of paper and attach it to this form.



5. The undersigned party acknowledges a continuing duty to inform the court of any cases in this or any other state that could affect the current proceeding.

Dated: _________________ ____________________________________

Party’s Signature Printed Name: __________________________ Address: _______________________________ City, State, Zip: _________________________ Telephone Number: ______________________ Fax Number: ___________________________ E-mail Address(es): ______________________

If a nonlawyer helped you fill out this form, he/she must fill in ALL the blanks below: This form was prepared for the {choose only one}: ( ) Petitioner ( ) Respondent. This form was completed with the assistance of: {name of individual} _____________________________________________________________ {name of business} ______________________________________________________________ {address} ______________________________________________________________________ {city} _______________________ {state} _____, {telephone number} _____________________

Documents

**IMPORTANT** - Pasco Clerk · imminent danger of becoming a victim of domestic violence, ... Supplemental Affidavit in Support of Petition for Injunction for Protection Against Domestic

IMPORTANT - Pasco Clerk · imminent danger of becoming a victim of domestic violence, ... Supplemental Affidavit in Support of Petition for Injunction for Protection Against Domestic