Florida Child Custody Affidavit

 

IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,
IN AND FORĀ 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:
FOLLOWING INFORMATION IS TRUE ABOUT CHILD # :
Child’s Full Legal Name:
Place of Birth: Date of Birth: Sex:
Child’s Residence for the past 5 years:

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

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

THE FOLLOWING INFORMATION IS TRUE ABOUT CHILD # :

Child’s Full Legal Name:
Place of Birth: Date of Birth: Sex:

Child’s Residence for the past 5 years:

Dates
(From/To)		 Address (including city and state) where child lived Name and present address of person child lived with Relationship to child
/
/
/
/
/
/
2. Participation in custody or time-sharing proceeding(s):
[Choose only one ]
2. 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.
2. 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 ]
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 ]
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 ]
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
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:
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} ( ) ( ) .This form was completed with the assistance of:
{name of individual}
{name of business}
{address}
{city} {state} {telephone number}

 

Contact Information

 

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