Florida Supreme Court Approved Family Law Form 12941D

Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA) Affidavit

Florida Supreme Court Approved Family Law Form 12.902(d) (02/18)

IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,

IN AND FOR COUNTY, FLORIDA

, Petitioner,

and

, Respondent.

UNIFORM CHILD CUSTODY JURISDICTION AND ENFORCEMENT ACT (UCCJEA) AFFIDAVIT

I, , being sworn, certify that the following statements are true:

1. The number of minor child(ren) subject to this proceeding is .

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:

THE FOLLOWING INFORMATION IS TRUE ABOUT CHILD # 2:

Child’s Full Legal Name:

Place of Birth: Date of Birth: Sex:

Child’s Residence for the past 5 years:

THE FOLLOWING INFORMATION IS TRUE ABOUT CHILD # 3:

Child’s Full Legal Name:

Place of Birth: Date of Birth: Sex:

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

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, jurisdiction, or country, concerning parental responsibility for, custody of, or time-sharing or visitation 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, jurisdiction, or country, concerning parental responsibility for, custody of, or time-sharing or visitation 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):

I HAVE NO INFORMATION of any parental responsibility, custody, time-sharing, or visitation proceeding pending in a court of this or any other state, jurisdiction, or country concerning a child subject to this proceeding.

I HAVE THE FOLLOWING INFORMATION concerning a parental responsibility, custody, time-sharing, or visitation proceeding pending in a court of this or another state concerning a child subject to this proceeding, other than set out in item 2.

Explain:

a. Name of each child involved in said litigation:

b. Type of proceeding:

c. Court and state:

d. Date of court order or judgment (if any):

e. Case Number:

4. Persons not a party to this proceeding:

I DO NOT KNOW OF ANY PERSON in this or any other state, jurisdiction, or country, who is not a party to this proceeding and who has physical custody or claims to have parental responsibility for, custody of, or time-sharing or visitation 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 parental responsibility for, custody of, or time-sharing or visitation with respect to any child subject to this proceeding:

a. Name and address of person:

has physical custody

claims parental responsibility or custody rights

claims time-sharing or visitation

Name of each child:

Relationship to child, if any:

b. Name and address of person:

has physical custody

claims parental responsibility or custody rights

claims time-sharing or visitation

Name of each child:

Relationship to child, if any:

c. Name and address of person:

has physical custody

claims parental responsibility or custody rights

claims time-sharing or visitation

Name of each child:

Relationship to child, if any:

5. Knowledge of prior child support proceedings:

The child(ren) described in this affidavit are NOT subject to existing child support order(s) in this or any other state, jurisdiction, or country.

The child(ren) described in this affidavit are subject to the following existing child support order(s):

a. Name of each child:

b. Type of proceeding:

c. Court and address:

d. Date of court order/judgment (if any):

e. Amount of child support ordered to be paid and by whom:

6. I acknowledge that I have a continuing duty to advise this Court of any parental responsibility, custody, time-sharing or visitation, 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.

7. A completed Notice of Confidential Information within Court Filing, Florida Rules of Judicial Administration Appendix to Rule 2.420 Form, is filed with this Affidavit.

I certify that a copy of this document was e-served mailed faxed and mailed hand delivered to the person(s) listed below on .

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 affidavit and that the punishment for knowingly making a false statement includes fines and/or imprisonment.

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:

[fill in all blanks] This form was prepared for the Petitioner Respondent

This form was completed with the assistance of:

Name of individual:

Name of business:

Address:

City: State: Zip code: Telephone number: