Florida Mandatory Disclosure Form

Certificate of Compliance with Mandatory Disclosure

IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,

IN AND FOR COUNTY, FLORIDA

CERTIFICATE OF COMPLIANCE WITH MANDATORY DISCLOSURE

I, , certify that I have complied with the mandatory disclosure required by Florida Family Law Rule 12.285 as follows:

1. FOR TEMPORARY FINANCIAL RELIEF, ONLY:

The date the following documents were served:

[ ] all that apply

a. Financial Affidavit (Filing of a Financial Affidavit cannot be waived.)

[ ] Florida Family Law Rules of Procedure Form 12.902(b) (short form)

[ ] Florida Family Law Rules of Procedure Form 12.902(c) (long form)

b. [ ] All personal (1040) federal tax, gift tax, and intangible personal property tax returns for the preceding year; or

[ ] Transcript of tax return as provided by IRS Form 4506; or

[ ] IRS forms W-2, 1099, and K-1 for the past year because the income tax return for the past year has not been prepared.

c. Pay stubs or other evidence of earned income for the 3 months before the service of the financial affidavit.

2. FOR INITIAL, SUPPLEMENTAL, AND PERMANENT FINANCIAL RELIEF:

The date the following documents were served:

[ ] all that apply

a. Financial Affidavit (Filing of a Financial Affidavit cannot be waived.)

[ ] Florida Family Law Rules of Procedure Form 12.902(b) (short form)

[ ] Florida Family Law Rules of Procedure Form 12.902(c) (long form)

b. [ ] All personal (1040) federal and state tax income returns, gift tax returns, and intangible personal property tax returns for the preceding 3 years;

[ ] IRS forms W-2, 1099, and K-1 for the past year because the income tax return for the past year has not been prepared.

c. Pay stubs or other evidence of earned income for the 3 months before the service of the financial affidavit.

d. A statement identifying the source and amount of all income for the 3 months before the service of the financial affidavit, if not reflected on the pay stubs produced.

e. All loan applications and financial statements prepared for any purpose or used for any purpose within the 12 months preceding the service of the financial affidavit.

f. All deeds to real estate in which I presently own or owned an interest within the past 3 years. All promissory notes in which I presently own or owned an interest within the last 12 months. All present leases in which I own an interest.

g. All periodic statements for the last 3 months for all checking accounts and for the last year for all savings accounts, money market funds, certificates of deposit, etc.

h. All brokerage account statements for the last 12 months.

i. Most recent statement for any pension, profit sharing, deferred compensation, or retirement plan and summary plan description for any such plan in which I am a participant or alternate payee.

j. The declarations page, the last periodic statement, and the certificate for any group insurance for all life insurance policies insuring my life or the life of my spouse.

k. All health and dental insurance cards covering either of me or my spouse and/or our dependent child(ren).

l. Corporate, partnership, and trust tax returns for the last 3 tax years, in which I have an ownership or interest greater than or equal to 30%.

m. All credit card and charge account statements and other records showing my(our) indebtedness as of the date of the filing of this action and for the prior 3 months. All promissory notes on which I presently owe or owed within the past year. All lease agreements I presently owe.

n. All premarital and marital agreements between the parties to this case.

o. If a modification proceeding, all written agreements entered into between the parties at any time since the order to be modified was entered.

p. All documents and tangible evidence relating to claims for special equity or nonmarital status of an asset or debt.

q. Any court order directing that I pay or receive spousal support (alimony) or child support.

I certify that a copy of this document was [one only] ( ) mailed ( ) faxed and mailed ( ) hand delivered to the person(s) listed below on .

I understand that I am swearing or affirming under oath to the accuracy of my compliance with the mandatory disclosure requirements of Fla. Fam. L. R. P. 12.285 and that, unless otherwise indicated with specificity, this disclosure is complete. I further understand that the punishment for knowingly making a false statement or incomplete disclosure includes fines and/or imprisonment.

Other party or his/her attorney:

Name:

Address:

City, State, Zip:

Fax Number:

Dated:

Telephone Number:

Fax Number:

STATE OF FLORIDA

COUNTY OF

Sworn to or affirmed and signed before me on by .

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW:

I, , a nonlawyer, located at , ,

, , helped ,

who is the [one only] [ ] petitioner or [ ] respondent, fill out this form.